Heartsworth Center For Nursing & Rehabilitation
Heartsworth Center For Nursing & Rehabilitation in Vinita, OK — inspection on September 18, 2025.
Found 1 citation. 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.
Inspection Findings
jeopardy to resident health or safety
Res #3, dated [DATE], showed in Section C the resident had a BIMS score of 15 which indicated their cognition was intact for decision making.A physician's order, dated [DATE], showed Res #3 was a full code.On [DATE] at 9:36 a.m., CNA #1 was asked to describe their involvement in the care of Res #3 that occurred on [DATE]. CNA #1 stated they were working on a different hall than the one Res #3 had resided.
They stated CNA #2 had come to them and stated Res #3 had died and they had never done the aftercare before. CNA #1 stated they asked CNA #2 if the resident was a DNR or full code because the aftercare was different.
They stated CNA #2 had replied they had not done CPR so they assumed there was a DNR and they would clean the resident up accordingly. CNA #1 stated they went to the hall where Res #3 was and cleaned the body. CNA #1 was asked what Res #3's body looked like.
They stated the upper body clothing was covered in a foul-smelling vomit and when they rolled the body to the sides during cleaning, more of the substance exited the resident's mouth.
They stated the skin looked normal except the veins looked bluer than a living person. CNA #1 was asked if there was any blue areas of the skin or any stiffness observed.
They stated the skin did not have any blue areas and the body was limp.On [DATE] at 9:49 a.m., CNA #2 was asked to describe their involvement in the care of Res #3 that occurred on [DATE]. CNA #2 stated they had gone into Res #3's room for their routine check and the resident did not respond when they spoke with them and did not appear to be breathing. CNA #2 stated they went to LPN #1 and gave them that information.
They stated LPN #1 entered the room and put a blood pressure measuring device on the resident's arm and checked Res #3's blood pressure.
They stated LPN #1 stated, She's dead. CNA #2 stated they asked LPN #1 what they should do to which the LPN replied, Clean (them) up. CNA #2 was asked what LPN #1 had done after telling them to clean them up. CNA #2 stated they saw LPN #1 go look at their computer but did not know what they were doing. CNA #2 stated they went to get help from CNA #1 because they had never cleaned a deceased body before. CNA #2 was asked to describe what they and CNA #1 had done regarding the cleaning of the body. CNA #2 stated they removed the resident's clothing and brief, then washed the body, brushed the resident's hair, then covered the body with a sheet. CNA #2 was asked to describe the resident's body when they had cleaned it.
They stated the skin looked pale all over. CNA #2 was asked if there was any discoloration to the skin such as blue or purple areas.
They stated the skin did not have any discoloration. CNA #2 was asked to describe if the body seemed stiff or limp.
They replied the body was limp. CNA #2 added the resident's body had vomit on it and when they rolled the body to the side to clean it, and vomit came out of the resident's mouth and nose and looked like there was some blood in it.On [DATE] at 10:54 a.m., the ADON was asked what information they had regarding Res #3's death on [DATE].
The ADON stated they found out about the death from LPN #1 in a text message which stated the resident was deceased and all they had done.
The ADON stated LPN #1 texted back and asked if they had performed CPR but did not get a reply.
The ADON stated they later texted again and asked if they had performed CPR and LPN #1 then called them.
They stated LPN #1 told them the resident had emesis (vomit) on them to which they replied that did not matter if the resident was a full code and if they were, they should have gotten CPR.
The ADON stated they then looked up Res #3's code status and found out the resident was a full code.
The ADON stated LPN #1 replied the resident was on hospice care and had a DNR.
The ADON stated they then went to the facility about 10:00 a.m. and Res #3's body had already been removed from the facility.
The ADON stated they checked with the resident's hospice service, and they did not have a DNR.
The ADON stated Res #3 should have received CPR on the day they had died.
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