Heartsworth Nursing: No CPR Given to Full Code Resident - OK
Federal inspectors who investigated the incident at Heartsworth Center for Nursing and Rehabilitation rated it immediate jeopardy, the most serious classification available under Medicare's oversight system, indicating the facility's failure placed residents in immediate risk of serious harm or death.
The sequence of events, as reconstructed from inspector interviews with two certified nursing assistants and the facility's assistant director of nursing, began when CNA 2 entered Resident 3's room for a routine check. The resident did not respond when spoken to and did not appear to be breathing. CNA 2 went to LPN 1 and reported what they had found.
LPN 1 entered the room and applied a blood pressure cuff to the resident's arm. Then the nurse said, "She's dead." CNA 2 asked what they should do. LPN 1 said, "Clean her up." CNA 2 watched LPN 1 walk back toward a computer. They did not see the nurse do anything else.
CNA 2 had never prepared a deceased person's body before. They went to find CNA 1, who worked on a different hall, and told them Resident 3 had died. CNA 1's first question was whether the resident was a DNR or a full code, because the aftercare process differed. CNA 2 said they hadn't performed CPR, so they assumed there must be a DNR, and the two aides proceeded accordingly.
When inspectors asked CNA 1 to describe what the body looked like, they said the upper clothing was covered 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. The skin looked normal, CNA 1 said, except the veins appeared bluer than on a living person. The body was limp. There were no blue or purple areas on the skin.
CNA 2's account matched. The skin was pale all over, they said, with no discoloration. The body was limp. When they rolled Resident 3 to clean her, vomit came from her mouth and nose, and there appeared to be blood in it. The two aides removed her clothing and brief, washed the body, brushed her hair, and covered her with a sheet.
Neither aide had been given accurate information about the resident's code status. Neither had been directed to check. The nurse who declared the death had not checked either, or if she had, she had reached the wrong conclusion, and she told no one.
The assistant director of nursing learned about the death from a text message sent by LPN 1. The text said the resident was deceased and described what had been done. The ADON texted back and asked whether CPR had been performed. LPN 1 did not reply. The ADON sent a second text asking the same question. This time LPN 1 called.
LPN 1 told the ADON the resident had vomit on her. The ADON said that didn't matter if the resident was a full code, and if she was a full code, she should have received CPR. The ADON then looked up Resident 3's code status in the facility's records and found what CNA 1 had tried to establish before the cleaning began: the resident was a full code.
When the ADON confronted LPN 1 with this, the nurse said the resident was on hospice care and had a DNR. The ADON checked with the resident's hospice service. There was no DNR on file there either.
The ADON arrived at the facility around 10:00 a.m. Resident 3's body had already been removed.
The ADON told inspectors directly: Resident 3 should have received CPR on the day she died.
What the inspection record captures, in the flat language of staff interviews, is a facility where a licensed nurse made a determination of death without apparent verification of the resident's code status, directed unlicensed aides to prepare the body, and then communicated the death to a supervisor by text message. The two aides who cleaned the body were working from an assumption, not a record. One of them had thought to ask the right question at the outset, and the answer they received was wrong.
There is no indication in the inspection record that LPN 1 attempted resuscitation, called for help, or consulted Resident 3's chart before declaring her dead and leaving the room. The nurse's explanation, offered only after the ADON pressed twice by text and once by phone, was that the resident was on hospice with a DNR. The hospice service said otherwise.
Vomit present in and around a person's mouth and nose at the time of discovery does not by itself establish that resuscitation was contraindicated or futile. The inspection report does not indicate that LPN 1 offered any clinical rationale for the decision beyond the hospice claim, which the ADON could not verify.
The two aides who carried out the aftercare were not the decision-makers. CNA 1 had asked the question that mattered before they ever entered the room. CNA 2 had done what they were told by the nurse responsible for the resident's care. The inspection record does not suggest either aide had access to the resident's chart or any reason to override the information LPN 1 had provided through omission.
Heartsworth Center for Nursing and Rehabilitation is located in Vinita, in Craig County in northeastern Oklahoma. The inspection was a complaint investigation, meaning someone reported the incident to regulators rather than it being discovered during a routine survey cycle. The inspection was conducted September 18, 2025.
The immediate jeopardy finding applied to a small number of residents. The inspection record does not describe corrective actions taken by the facility or specify what happened to LPN 1 following the ADON's discovery that Resident 3 had no DNR.
What the record does describe is the moment the ADON arrived at the facility after learning what had happened. They had texted twice. They had called. They had pulled the chart. They had called the hospice service. By the time they walked through the door, Resident 3 was already gone.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Heartsworth Center For Nursing & Rehabilitation in Vinita, OK was cited for violations during a health inspection on September 18, 2025.
The resident did not respond when spoken to and did not appear to be breathing.
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.