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Complaint Investigation

Heritage Hills Living & Rehabilitation Center

November 24, 2025 · Mcalester, OK · 411 North West Street
Citations 3
CMS Rating 1/5
Beds 81
Provider ID 375317
Healthcare Facility
Heritage Hills Living & Rehabilitation Center
Mcalester, OK  ·  View full profile →
Inspection Summary

HERITAGE HILLS LIVING & REHABILITATION CENTER in MCALESTER, OK — inspection on November 24, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

could not risk the possibility that the abuse occurred.

The DON stated they suspended LPN #1 as soon as the administration was notified and later terminated LPN #1.

The DON stated LPN #1 did not work in the facility after they were informed of the allegation. On 10/22/25 at 6:00 p.m., the administrator stated right after the incident, they in-serviced all staff on abuse: what was abuse, what to do if you suspect abuse, what were the regulations regarding abuse, and what to do if you're too stressed with a resident to provide immediate care.

The administrator stated they routinely in-serviced their staff on abuse but incidents like this still happened. On 10/22/25 at 6:20 p.m., CNA #2 stated they were in the hall with another CNA when LPN #1 approached and said Resident #1 was on the ground in the inner courtyard and needed help getting up. CNA #2 stated they retrieved the lift and sling to raise the resident from the ground. CNA #2 stated when they entered the courtyard, they saw Resident #1 laying in a large puddle of liquid and thought they may have urinated on themselves but quickly realized there was too much liquid and the resident was wet in places where urine would not have flowed. CNA #2 stated Resident #1 said LPN #1 had poured a pitcher of water over them. CNA #2 stated LPN #1 corrected the resident and said they poured water on the resident's feet to clean them of feces. CNA #2 stated the amount of liquid they saw and where Resident #1 was wet did not match with the statement LPN #1 said about washing the resident's feet. CNA #2 stated they assisted the resident to the shower and helped them shower. CNA #2 stated the resident had scrapes on their elbow, hip, and knee. CNA #2 stated Resident #1 was upset and told them that LPN #1 pushed them from the chair, poured a cup of water on their feet, left and returned to the courtyard with a pitcher of ice water, poured the ice water onto Resident #1, and then used profanity to tell them that was what they deserved for defecating on themselves. CNA #2 stated the allegation sounded like abuse, but they were not sure how to proceed since they were to report any allegation of abuse to their charge nurse which was LPN #1.

They stated they asked other staff for help and was able to contact the facility administration and inform them of events. CNA #2 stated LPN #1 left the facility and everyone wrote statements as to what they saw and heard.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Hills Living & Rehabilitation Center

411 North West Street McAlester, OK 74502

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, and interview, the facility failed to secure chemicals which had the potential to harm residents if the chemicals were touched, inhaled, or ingested.

The DON identified 50 residents resided in the facility.

Findings: On 10/22/25 at 11: 00 a.m., there were no wandering residents observed on the East hall. At the end of the East hall was an unsecured resident room which was used for storage.

There was no way to lock the storage room door and located behind the door was six 1-gallon sized bottles of unsecured chemicals.

The chemicals included three 1-gallon bottles of ZEP Wet Look Floor Polish, two 1-gallon bottles of Floor Front Floor Finish, and a gallon bottle of Betco Advanced Alcohol Gel Sanitizer.

Each of the 6 bottles of chemicals had a warning label which read to keep out of reach of children.On 10/22/25 at 11:07 a.m., the DON observed the unsecured chemicals in the storage room. An undated and unnamed facility policy showed all chemicals must be secured with locks and accessible to only housekeeping and maintenance.The MSDS for Floor Front Floor Finish, dated 05/15/19, showed the chemical may be harmful if swallowed, may cause skin irritation, may cause eye irritation, and inhalation of vapors or mist may cause respiratory irritation.

The MSDS for Zep Wet Look Floor Polish, dated 05/24/19 showed the vapors may cause irritation to the eyes respiratory system and the skin.

The MSDS showed to avoid contact with skin and eyes; smoking, eating and drinking should be prohibited in the application area; and to dispose of rinse water according to local and national regulations.

The MSDS for Advanced Alcohol Gel Sanitizer, dated 06/08/22, showed the chemical was dangerous; was a highly flammable liquid and vapor; and caused serious eye irritation. On 10/22/25 at 11:07 a.m., the DON stated all chemicals were to be locked up and only accessible to housekeeping and maintenance.

The DON stated the staff knew better than to store chemicals in an unsecured room.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Hills Living & Rehabilitation Center

411 North West Street McAlester, OK 74502

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and interview, the facility failed to securely store protected health information.

The DON identified 50 residents resided in the facility.

Findings:On 10/22/25 at 11: 00 a.m., at the end of the East hall was an unsecured resident room with three 4-drawer tall file cabinets and one 5-drawer tall file cabinet. On top of one file cabinet were loose papers and files with residents' protected health information, including name, birthdate, social security numbers, insurance information, labs, and physician's progress notes.

None of the file cabinet drawers were locked and two of the 4-drawer file cabinets held more resident clinical records. On 10/22/25 at 11:07 a.m., the DON observed the unsecured storage room and resident records. An undated and unnamed facility policy showed all resident records were to be behind locked doors at all times with keys kept in the administrator's office.On 10/22/25 at 11:07 a.m., the DON stated all resident records should be secured with a lock and with limited staff access.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MCALESTER, OK, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HERITAGE HILLS LIVING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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