Heartsworth Center For Nursing & Rehabilitation
For profit - Limited Liability company
146 Beds
RIVERS EDGE OPERATIONS
Data: November 2025
Trust Grade
38/100
#233 of 282 in OK
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Heartsworth Center for Nursing & Rehabilitation has a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #233 out of 282 facilities in Oklahoma, placing it in the bottom half, and is the only nursing home in Craig County. While the facility is improving, going from 18 issues in 2023 to 13 in 2024, it still faces significant challenges. Staffing is rated average with a turnover rate of 55%, which is concerning but aligns with the state average. Specific incidents include failing to adequately address wandering behavior for a resident, serving food at unsafe temperatures, and not ensuring that all residents received three balanced meals daily.
- Trust Score
- F
- In Oklahoma
- #233/282
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $24,850 in fines. Higher than 74% of Oklahoma facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 18%
No red flags
18 → 13 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 18 issues
2024: 13 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Oklahoma average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Oklahoma avg (46%)
Higher turnover may affect care consistency
Federal Fines: $24,850
Below median ($33,413)
Minor penalties assessed
Chain: RIVERS EDGE OPERATIONS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
May 2024
13 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to assist a resident with their meal in a dignified manner for one (#10) of eight residents observed for dining.
The DON identi...
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Based on observation, record review, and interview, the facility failed to assist a resident with their meal in a dignified manner for one (#10) of eight residents observed for dining.
The DON identified three residents who required total assistance with meals.
Findings:
The facility's Assistance with Meals policy, documented that residents who could not feed themselves would be fed with attention to dignity. As examples, the policy documented not to stand over residents while assisting them with their meals and to keep interactions with other staff to a minimum while assisting residents with their meals.
On 04/29/24 at 10:53 a.m., Resident #10 was reclined in a geri-chair, in the dining room. Facility staff stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with various other staff members as they stood beside Resident #10.
On 05/01/24 at 11:20 a.m., Resident #10 was reclined in a geri-chair, in the dining room. CNA #4 stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with various other staff members as they stood beside Resident #10.
On 05/02/24 at 1:09 p.m., CNA #4 stated when they assisted a resident with their meal, they placed a protective cover over the resident's clothing and sat in front of the resident to assist with the meal. CNA #4 stated they thought in was more sociable to sit while assisting a resident with their meal because you could talk with the resident.
On 05/02/24 at 1:21 p.m., CNA #5 stated if they assisted a resident with their meal, they sat beside them. The CNA $5 stated when they sat beside the resident, they could have a more casual conversation with them. The CNA#5 stated if they were to stand while they assisted the resident, the act would feel clinical or as though they were looming over the resident.
On 05/02/24 at 2:24 p.m., the DON stated they expected their staff to sit down to assist a resident with their meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide education about advance directives and provide an opportunity for a resident to have or decline an advance directive for one (#63) ...
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Based on record review and interview, the facility failed to provide education about advance directives and provide an opportunity for a resident to have or decline an advance directive for one (#63) of 24 sampled residents reviewed for advance directives.
A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility.
Findings:
A review of Resident #63's EMR found any documentation of an advance directive. The EMR did contain an order for full code but no paperwork that it was discussed with the resident or a representative was found in the records.
On 05/01/24 at 7:25 a.m., the ADON stated they had reviewed Resident #63's records and did not find documentation of an advance directive. They stated they did find a physician's order for full code status but not the paperwork that code status was discussed with the resident or a representative.
On 05/01/24 at 7:59 a.m., the ADON stated the resident did not have an advance directive and there was no documentation in their records they were given education on advance directives or given the opportunity to accept or decline the creation of one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to provide privacy for one (#44) of one resident observed to have a facility camera in their room.
The DON identified there were two residents ...
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Based on observation and interview, the facility failed to provide privacy for one (#44) of one resident observed to have a facility camera in their room.
The DON identified there were two residents for which the facility had placed a camera in the residents' rooms.
Findings:
The comprehensive assessment, dated 01/20/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care.
The quarterly assessment, dated 04/10/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care.
On 04/29/24 at 09:30 a.m., Resident #44 was interviewed in their room while they were in bed. There was a camera positioned on the opposite wall from the resident's headboard and faced toward the bed.
Resident #44 stated they had difficulty hearing. The resident responded to open ended questions, including questions regarding the use of a camera in their room, with inappropriate responses of yes or no.
On 04/29/24 at 9:56 a.m., RN #1 stated Resident #44 had a camera in their room. There was a small portable monitor located on the top of the half wall which ran along the front of the nurses' station.
RN #1 pressed a button on a small portable monitor and the screen depicted Resident #44 lying in their bed. The RN #1 stated the resident often fell when they transferred themselves to and from the bed to their wheelchair. The RN #1 stated the camera had been used at least since the first of the year when they had started working with the resident.
04/29/24 at 2:28 p.m., Resident #44 laying perpendicular in bed with legs stretched out and supported by seat of wheelchair. RN #1 performed an assessment on Resident #44. The camera was in the room, pointed toward the bed.
On 04/29/24 at 2:30 p.m., the camera monitor was on the half wall in front of the nurses' station. The monitor laid on its back with the screen facing upward toward the ceiling. Other residents, visitors, and staff were observed to walk, propel, and/or stand within a few feet of the monitor.
On 04/30/24 at 11:15 a.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the interior of the nurses' station. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor.
On 04/30/24 at 2:40 p.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the ceiling. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor.
On 05/01/24 at 10:25 a.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the interior of the nurses' station. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor.
On 05/01/24 at 2:32 p.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the ceiling. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor.
On 05/02/24 at 9:57 a.m., RN #2 stated they did not know of the camera until recently when they noticed it was on the wall. They stated when they had inquired about the camera, they were told it had been there for a few months.
On 05/02/24 at 10:06 a.m., RN #1 stated the staff provided for privacy by pulling privacy curtains for the residents in a semi-private room and closing bedroom doors before providing resident care. The RN stated to provide privacy for Resident #44, they kept the monitor facing inward toward the nurses' station. The RN #1 stated the screen timed out after a minute or so but all you had to do was press a button on the monitor to view the screen again.
On 05/02/24 at 10:49 a.m., the ADON stated the facility notified the Power of Attorney, family, or other responsible party for the resident of the use of the camera as a fall intervention. The ADON stated the care plan should document the use of the camera as a fall intervention.
The ADON reviewed the clinical chart for Resident #44 and stated the resident was their own responsible party. They stated the resident's care plan did not address the use of a camera. The ADON stated there was no physician's order for the use of the camera and no documentation of when or why the camera was used. The ADON stated there was no documentation Resident #44 was notified or agreed to the use of a camera in their room.
On 05/02/24 at 10:50 a.m., the DON stated the camera was used as a last ditch effort fall intervention before utilizing a private sitter. The DON stated the monitor was to be secluded in the nurses station or carried by a staff member in a manner to allow for privacy. The DON stated the use of a camera should be routinely reviewed for the appropriateness as a fall intervention. The DON stated the facility did not have a procedure for the use of a facility's camera in a resident's room.
On 05/02/24 at 10:51 a.m., the administrator stated the facility did not have a policy or procedure for the facility's use of a camera in a resident's room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the accuracy of a baseline care plan for one (#219) of two residents sampled for baseline care plan.
The administrator reported the ...
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Based on record review and interview, the facility failed to ensure the accuracy of a baseline care plan for one (#219) of two residents sampled for baseline care plan.
The administrator reported the census was 73.
Findings:
An undated facility policy titled Care Plans-Baseline read in part, .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident .
Resident #219 had diagnoses which included hypertension and anemia.
A baseline care plan, dated 04/17/24, documented the resident had a pressure ulcer upon admission.
An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds.
On 05/01/24 at 1:20 p.m., the ADON stated she was unaware the resident had any skin issues at admit.
On 05/02/24 at 9:42 a.m., MDS coordinator #2 stated she was responsible for Resident #219's baseline care plan and the information regarding the pressure ulcer was inaccurate.
On 05/02/24 at 1:20 p.m., the DON stated that they were ultimately responsible for ensuring the accuracy of baseline care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the consulting pharmacist documented the correct dosage of a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for one (#11) of five residents whose clinical records were reviewed for unnecessary medications.
The ADON identified 16 residents who received psychotropic medications.
Findings:
The physician's order, dated 05/11/23, documented the resident was to receive Zoloft 200 mg daily.
The request for a gradual dose reduction, dated 06/17/23, documented the resident received Zoloft 100 mg daily.
The physician's order, dated 06/26/23 was written on the pharmacist's request for gradual dose reduction and documented to decrease Zoloft to 50 mg daily.
The physician's order, dated 07/13/23, documented the resident was to receive Zoloft 200 mg daily.
On 05/02/24 at 9:42 a.m., the ADON stated the pharmacist documented an incorrect dosage on the request for gradual dose reduction and the physician may have based their decision to reduce the medication on the inaccurate dosage documented on the gradual dose reduction. The ADON stated the resident had gone to the hospital on [DATE] and returned to the facility the same day. The ADON stated it was about that time when the facility identified a problem with the floor nurses not reconciling or confirming the orders with the physician once a resident returned from the hospital. The ADON stated they were now responsible for entering new physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to notify the physician of a wound for one (# 219) of one resident sampled for wounds.
The ADON identified seven residents in th...
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Based on observation, record review, and interview, the facility failed to notify the physician of a wound for one (# 219) of one resident sampled for wounds.
The ADON identified seven residents in the facility with wounds.
Findings:
An undated facility policy titled Change in a Resident's Condition or Status read in part, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents' medical/mental condition and/or status .The nurse will notify the residents' attending physician or physician on call when there has been a . need to alter the residents' medical treatment significantly .
Resident #219 had diagnoses which included hypertension and anemia.
An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds.
A nurse note, dated 04/28/24 at 5:42 pm, documented the resident had an open sore on their right buttocks.
A review of Resident #219's medical record did not document the physician had been notified regarding the open area.
On 05/01/24 at 9:40 am, LPN #1 stated they were aware of a spot on the resident's buttocks and that they had been treating it with barrier cream. They also stated they had not contacted the physician regarding the spot.
On 05/01/24 at 9:54 am, an open area was observed on Resident #219's right buttock.
On 05/01/24 at 9:55 am LPN #1 stated the area was bigger than it was the last time they saw it on 04/29/24. LPN #1 also stated she had not notified the physician on 04/29/24 because the area was not open.
On 05/01/24 at 12:08 pm, the ADON stated their expectation is that anyone that notices an open area should report it immediately so the physician could be notified.
On 05/02/24 at 1:20 pm the DON stated the physician should have been notified as soon as the wound was discovered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to prevent a medication room door from being propped open by a chair and the medication room being open and unattended by appropriate staff.
A ...
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Based on observation and interview, the facility failed to prevent a medication room door from being propped open by a chair and the medication room being open and unattended by appropriate staff.
A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility.
Findings:
The facility's Medication Labeling and Storage policy, dated 02/2023, read in part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.
On 04/30/24 at 6:51 a.m., the facility medication room door was found propped open with a chair and the medication room unattended. There were no staff members observed inside the room or in the hallways next to the room who may have been observing the room. Four locked medication carts were located in the medication room. Various types of resident medications were found in bins located on shelves around the medication room. No unsecured controlled medications were observed.
On 04/30/24 at 6:55 a.m., LPN #1 entered the medication room. They stated they someone had used a chair to hold the door open but they did not know who. They stated they had not done so. They stated the medication room should never be left open and unattended. They stated a resident could have entered and taken medications which could have harmed them.
On 04/30/24 at 7:29 a.m., LPN #2 stated they had left the medication room door propped open with a chair. They stated they were focused on a resident being sent to out to a hospital that they did not think about the door being left open. They stated they it was not something they would normally do. They stated they understood the consequences of leaving the medication room open and unattended could result in a resident or other person taking medications and harming themselves.
On 04/30/24 at 7:56 a.m., the ADON stated a search of the medication room found no missing medication.
On 04/30/24 at 8:45 a.m., the DON stated LPN #2 had been counseled about the leaving the medication room open. They stated that should have never occurred and the medicating room must be secured at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room.
The administrator reported the fa...
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Based on observation and interview, the facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room.
The administrator reported the facility census was 73.
Findings:
On 04/30/24 at 10:25 am, Laundry Employee #1 reported the sign on the dryer indicated the lint screen should be cleaned every 4 hours, but when they were busy, they only cleaned it every eight hours or so.
On 04/30/24 at 10:25 am, signs were observed to be affixed to all three dryers in the laundry room, these signs stated the lint screens were to be cleaned every 4 hours.
On 04/30/24 at 10:30 am Laundry Employee #1 was asked to remove the cover to expose the lint screen on one of the dryers. Once the cover was removed a considerable amount of lint was observed to be covering the screen. The employee stated they had not cleaned the lint screens today, but they assumed the screens had been cleaned yesterday.
On 05/02/24 at 1:50 pm, the maintenance supervisor stated that laundry employees were responsible for cleaning the lint screen and maintenance staff were responsible for cleaning the lint around the fire box.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to include a focus of wandering in a comprehensive care plan for one (#4) of two residents reviewed for wandering.
The ADON identified two res...
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Based on record review and interview, the facility failed to include a focus of wandering in a comprehensive care plan for one (#4) of two residents reviewed for wandering.
The ADON identified two residents in the facility that wandered.
Findings:
A facility Elopements and Wandering Resident policy, dated 01/01/20, read in part, The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with with their person-centered plan of care addressing the unique factors contributing to wandering or elopement.
Resident #34 had diagnoses which included recurrent depressive disorder.
A progress note, dated 01/26/24 at 8:08 a.m., documented the Resident #34 had been wandering and continued attempting to enter other residents' rooms.
A progress note, dated 01/26/24 at 10:02 a.m., documented the Resident #34 was found in their room with the shoes of a male resident.
A progress note, dated 01/26/24 at 5:12 p.m., documented the Resident #34 had attempted to enter the kitchen while calling our for their mother.
A progress note, dated 02/05/24 at 3:20 p.m., documented required redirection from wandering into the rooms of other residents.
A facility Wandering Risk Scale , dated 0225/24, documented the Resident #34 had score a 14 on the risk tool and was documented to be a high risk for wandering.
A progress note, dated 03/11/24 at 12:39 p.m., documented the Resident #34 wanders around the facility.
A quarterly MDS assessment, dated 03/14/24, documented the Resident #34 cognition was moderately impaired.
A review of Resident #34's comprehensive care plan found no focus, goal, or intervention regarding wandering. A focus for falls was in the care plan that documented the resident had fallen on 02/09/24 due to confusion and wandering. One of the interventions for the fall focus was to speak to the resident's family about a locked unit. The goal and other intervention for the fall focus did not address wandering.
On 04/30/24 at 7:26 a.m., the ADON stated Resident #34 did wander.
On 05/01/24 at 11:37 a.m., CNA #2 stated the Resident #34 did wander a lot a few months ago but she has since declined and does so less.
On 05/01/24 at 11:46 a.m., LPN #2 stated the Resident #34 has really slowed down as far as wandering and that sometimes they may try to go into another resident's room.
On 05/02/24 at 09:20 a.m., MDS Coordinator #1 reviewed Resident #34's medical record and stated the resident does not have focus on wandering. They stated they got their ideas for the care plan focuses from documentation in a residents medical record. They stated they do also talk with the staff about each resident when they make out the care plans. They stated that since there were progress notes about wandering in Resident #34's medical record they should have care planned wandering. They stated they were not sure why it was not care planned in the past.
On 05/02/24 at 1:14 p.m., the DON stated the care plan system at the facility was broken and the facility leadership will be working to fix it. They stated they need every IDT member to be involved in the care plan meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to serve foods at a palatable temperature from one of two kitchen service areas.
The DON identified 40 residents who ate meals s...
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Based on observation, record review, and interview, the facility failed to serve foods at a palatable temperature from one of two kitchen service areas.
The DON identified 40 residents who ate meals served from the satellite kitchen.
Findings:
The facility policy titled Food and Nutrition Services, read it part, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.
On 05/01/24 at 11:15 a.m., the satellite kitchen was observed. The mid-morning meal, including breakfast and lunch style options were observed on the steam table. The steam table was not producing steam. The back and sides of the steam table felt only warm to the touch. The holding temperature of the sausage patties was 94 degrees Fahrenheit. The holding temperature of the soup from 118 degrees Fahrenheit.
On 05/01/24 at 11:16 a.m., [NAME] #1 stated they were not sure what the holding temperature was for hot foods. The cook stated the steam table was turned on about 7:00 a.m. and left until they were finished with the evening meal. The cook stated they thought the steam table was not hot enough to keep the food hot due to one steam table burner not working and the low water level within the steam table. The [NAME] #1 pointed to a line inside the steam table water reservoir. The water level appeared approximately three inches below the line the cook pointed to.
On 05/02/24 at 10:15 a.m., the steam table was observed with [NAME] #2. The steam table did not produce steam. The sides of the steam table were warm to the touch. [NAME] #2 stated the holding temperature of hot foods was at least 135 degrees Fahrenheit. The cook measured the water in the steam table reservoir in two places. The water measured 128 degrees Fahrenheit at the back of the reservoir and 146 degrees Fahrenheit on the side where the knobs controlling the steam table temperature were located. The [NAME] #2 stated they had noticed trouble with the steam table maintaining temperature and had notified the maintenance department last week about it.
On 05/02/24 at 1:30 p.m., the dietary manager stated the holding temperature for hot food was to be greater than 135 degrees Fahrenheit. They stated food temperatures were measured just before sending food from the main kitchen to the satellite kitchen and again immediately after placing the food on the steam table and starting service to the residents. The dietary manager stated they did not measure the holding temperature of the food again.
The dietary manager was asked if measuring the temperature of the hot food as soon as it was placed on the steam table was an accurate measurement of the holding temperature of the hot foods during the entirety of the meal service. The dietary manager stated no. They stated measuring the temperature at the start of meal service gave the staff what the food temperature was at the start of of the meal and not what the holding temperature was of the food.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure three substantive meals were served daily.
The ADON reported 73 residents received meals from the kitchen.
Findings:
An undated faci...
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Based on record review and interview, the facility failed to ensure three substantive meals were served daily.
The ADON reported 73 residents received meals from the kitchen.
Findings:
An undated facility policy titled Frequency of Meals, read in part, .Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care .
A handwritten document provided by the DM documented that east hall had breakfast served at 7:30 am, the snack cart went out at 7:30 am, brunch was served at 10:30 am, the snack cart went out again around 1:30 pm, supper was served at 4:30 pm, and the snack cart went out again at 6:30 pm.
On 04/29/24 at 8:32 am, the DM stated that a breakfast snack was served in the morning and then brunch which has breakfast items was served. They also stated a midday snack was served then an evening meal was served around 4:30 pm followed by an evening snack.
On 05/02/24 at 9:10 am, the DM stated that a hot breakfast was served on the skilled unit, but other residents were served a continental breakfast consisting of pastries, cold cereal, oatmeal, or yogurt. The DM further stated that the residents could request a hot breakfast, but it was not offered to them.
On 05/02/24 at 11:40 am, CMA #2 stated breakfast was more of a snack than a meal.
On 05/02/24 at 11:49 am, LPN #2 stated she would not consider the breakfast served in the facility a substantial meal.
On 05/02/24 at 11:54 am, [NAME] #1 stated the residents on east hall received a hot meal for breakfast but the other residents in the facility did not.
On 05/02/24 at 11:58 am, CMA #1 stated the facility served a continental breakfast not a traditional breakfast.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain the physical environment of the main kitchen and failed to serve cold foods in the satellite dining room in a sanitary manner.
The ...
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Based on observation and interview, the facility failed to maintain the physical environment of the main kitchen and failed to serve cold foods in the satellite dining room in a sanitary manner.
The DON identified 79 residents who ate meals prepared in the main kitchen.
Findings:
On 04/29/24 at 8:32 a.m., the kitchen was observed to not have a dedicated handwashing sink.
On 04/29/23 at 8:32 a.m., the dietary manager stated the staff used the two compartment sink to wash their hands. The dietary manager stated the two compartment sink was used to fill pots with with water and other food preparation needs.
On 04/29/24 at 8:33 a.m., the kitchen was observed to have:
- missing and broken baseboards,
- holes in the ceiling,
- rusted air vents and lighting fixtures in the ceiling,
- multiple yellow and orange water stains on the ceiling,
- peeling paint located on the ceiling and above the food preparation areas,
- no dedicated hand washing sinks in the main or satellite kitchens,
- an unsecured bottom grill hanging from under the left door of the two door refrigerator, and
- and two (approximately one inch thick and four inch by eight foot) wood beams nailed across the ceilings stained, sagging, and peeling paint.
On 04/29/24 at 8:45 a.m., the satellite kitchen was observed with the dietary manager. The satellite kitchen was observed to not have a sink.
On 04/29/24 at 8:45 a.m., the dietary manager stated the kitchen staff assigned to the satellite kitchen were to wash their hands in the sink located on the opposite side of the dining room.
On 05/01 at 11:30 a.m., multiple nursing staff were observed passing trays from the satellite kitchen. The staff were observed to:
- passed trays to residents in the satellite dining room,
- assisted residents with positioning themselves near the table, and
- prepared the resident's plate (cutting the food, positioning utensils, plate, and drinks within reach of the resident), and
- plate and serve peaches in syrup from a clear container and cottage cheese from a container without sanitizing their hands.
The facility staff were observe to place the lid of the peaches container on the island counter with the interior or the lid in contact with the counter top before securing the lid back on top of the container.
Between the observations of nursing staff plating cold foods from the dining room island, Resident #20 was observed to plate themselves peaches and cottage cheese from the dining room island without washing or sanitizing their hands.
Without sanitizing their hands, the nursing staff were observed to serve cold foods located on the island in the satellite dining room.
On 05/02/24 at 1:30 p.m., the dietary manager stated the ceiling damage was there when they started working and they did not know when or how the damage occurred.
On 05/02/24 at 2:25 p.m., the DON stated cold foods should be served from the satellite kitchen by the kitchen staff to ensure food was served in a sanitary manner.
On 05/02/24 at 2:30 p.m., the kitchen was observed with the administrator. The administrator stated the facility had a pipe burst in the ceiling one holiday and maintenance had made the necessary repairs for food service to continue. The administrator stated there had never been dedicated handwashing sinks in the main or satellite kitchens.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide residents binding arbitration agreements that:
a. informed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide residents binding arbitration agreements that:
a. informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care; and
b. does contains an explicit acknowledged by the resident or their representative that they understood the provisions of the agreement; and
c. does not include the name of a second nursing facility, in which the resident does not reside or is aware of, in the agreement for two (#50 and #63) of two sampled resident reviewed for arbitration agreements.
The facility SSD stated 60 residents that resided in the facility had signed binding arbitration agreement.
Findings:
A facility Binding Arbitration Agreements policy, dated 07/18/19, read in part, This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility .When explaining the arbitration agreement, the facility shall:
a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.
1. Resident #50 was admitted to the facility on [DATE].
A review of the residents medical record found a digital copy of a binding arbitration agreement signed by the resident on 02/03/23. The agreement did not document the resident could be admitted to the facility without entering into the agreement and did not contain a statement the resident or their representative explicitly understood the provisions of the agreement. The document also contained in one paragraph the name of a second skilled nursing facility.
2. Resident #63 was admitted to the facility on [DATE].
A review of the resident medical record found a digital copy of a binding arbitration agreement signed by the resident on 03/21/24. The agreement did not document the resident could be admitted to the facility without entering into the agreement and did not contain a statement the resident or their representative explicitly understood the provisions of the agreement. The document also contained in one paragraph the name of a second skilled nursing facility.
On 05/02/24 at 11:53 a.m., the SSD stated they understood a resident was not required to sign an arbitration agreement to be admitted and received services at the facility. They stated if a resident did not want to sign the agreement the SSD would make a note at the bottom of the agreement. They stated the binding arbitration agreement they facility used did not state a person could still be admitted and receive services if they did not enter into a binding arbitration agreement. They stated there was not a section of the agreement that stated the resident or their representative explicitly understood the provisions of the agreement. They stated they are unaware of a policy and procedure related to arbitration agreements at the facility.
At 12:25 p.m. Resident #50 stated they did not recall signing a binding arbitration agreement when they were admitted and stated the facility staff gave them so much paperwork they did not know what they were signing. The resident had no knowledge of the second nursing facility included in the agreement.
At 12:28 p.m., Resident #63 stated they did not know what a binding arbitration agreement was and could not recall if they had signed one. They stated they did not know of the second nursing facility included in the agreement.
At 12:58 p.m., the Administrator stated the current owners of the facility did use binding arbitration agreements and had adopted the arbitration agreement form from the previous owners after the purchase of the facility. They stated that was the form they were using. They stated they understood the shortcomings of the agreement.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent a nurse aide whose CPR certification did not include hands-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent a nurse aide whose CPR certification did not include hands-on training and an in person skilled assessment, from providing chest compressions to a resident who was deemed by staff to require cardiopulmonary resuscitation for one (#1) of one sampled resident reviewed for quality of care.
A midnight census report, dated [DATE], documented 72 residents resided in the facility.
Findings:
Resident #1 had diagnoses which included Cardiomyopathy, chronic congestive heart failure, atherosclerotic heart disease, and morbid obesity.
A Emergency Procedure - Cardiopulmonary Resuscitation policy, revised date February 2018, read in part, .Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain [organization names withheld] certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) .
A certificate of completion for CPR, dated [DATE], documented CNA #1's training was the online only version.
A progress note, created date [DATE] at 10:40 p.m., documented on [DATE] at 8:00 p.m., Resident #1 had received cardiopulmonary resuscitation at the facility.
On [DATE] at 10:52 a.m., RN #1 reported Resident #1 had required CPR. They stated they had told CNA #1 they needed to start CPR then departed to find assistance to transfer the resident from a recliner to the floor. They stated, another nurse called 911 and when they returned with assistance, they transferred the resident to the floor and began CPR. They stated they had not witnessed CNA #1 do any part of the CPR.
At 1:18 p.m., CNA #2 stated they had witnessed CNA #1 doing CPR. They stated EMT's had taken over within five minutes of the resident having been placed on the floor but could not give the exact time.
At 2:05 p.m., CNA #1 stated they had performed chest compression on Resident #1 while they were still in the recliner for a period of less than one minute. They stated it was very brief and they were uncertain of the time as they were not paying attention to a clock at the time. They stated the other staff returned quickly and transferred the resident to the floor and performed CPR. They stated that EMT's were on the scene in about five minutes from the time the resident was found without a pulse.
On [DATE] at 11:27 a.m., the ADON stated they were unaware that CNA had performed chest compressions without the required training, and they would ensure all staff were certified correctly as required in their policy.
Mar 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued SN ABN noti...
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Based on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued SN ABN notices for two (#10 and #36) of three residents reviewed for beneficiary notices.
The facility identified 28 residents who were discharged from part A skilled services with benefit days remaining in the previous six months.
Findings:
1. Res #10 was admitted to part A skilled services on 01/19/23, discharged from skilled services on 03/01/23, and remained in the facility.
2. Res #36 was admitted to part A skilled services on 01/23/23, discharged from skilled services on 02/17/23, and remained in the facility.
On 03/28/23, the social services director was asked to provide ABN and NOMNC notifications for Res #10 and Res #36.
On 03/28/23 at 12:47 p.m., the social services director provided a NOMNC notice for Res #10 and Res #36. She stated she was unaware SN ABN CMS-10055 forms should have been provided to Res #10 and Res #36.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a new serious mental disorder to the state fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a new serious mental disorder to the state for a level II PASRR evaluation for one (#15) of two residents sampled for PASRR screening and evaluations.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
Res #15 admitted [DATE] with diagnoses which included psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia.
A PASRR level I, dated 03/06/12, documented Res #15 did not have a diagnosis of serious mental illness.
On 10/15/18 Res #15 received a new diagnosis of schizoaffective disorder.
An annual MDS, dated [DATE], documented a diagnosis of schizophrenia.
On 03/29/23 at 10:59 a.m., the SSD was asked for Res #15's level two pre admission screening and resident review.
On 03/29/23 at 11:58 a.m., the SSD stated she had called the Oklahoma Health Care Authority and the resident did not have a new PASRR screening completed in 2018.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive care plan for diuretic use for one (#21) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive care plan for diuretic use for one (#21) of five residents reviewed for unnecessary medications.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
Res #21 admitted [DATE] and had diagnoses which included chronic heart failure, hypertension, and peripheral vascular disease.
A physician order, dated 01/26/23, documented to administer Bumex (a loop diuretic) 1 mg two times a day for congestive heart failure.
A significant change MDS, dated [DATE], documented the resident received a diuretic medication seven out of seven days during the review period.
A care plan, reviewed 03/02/23, did not document Res #21's diuretic use.
On 03/29/23 at 1:59 p.m., the LTC MDS coordinator stated Res #21's care plan did not include the diuretic. She stated the diuretic should have been in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure one (#39) of five residents observed during med pass had an accurate medication reconciliation count.
The Resident Census and Conditio...
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Based on observation and interview, the facility failed to ensure one (#39) of five residents observed during med pass had an accurate medication reconciliation count.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
1. A physician order for Res #49, dated 03/22/23, documented morphine 10 mg/ml administer 0.25 ml sublingual daily.
On 03/29/23 at 8:45 a.m., CMA #1 was observed during medication pass. CMA #1 notified RN #1 there was an error on the narcotic count sheet. The narcotic count sheet documented 12 syringes of morphine remaining. The medication cart contained 13 syringes of morphine.
On 03/29/23, at 9:00 a.m., RN #1 called the DON to the medication cart due to the discrepancy with the morphine for Res #49. The DON stated the night shift CMA had documented the medication as given but did not administer the morphine. The DON stated the omission of the morphine was a medication error.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor one (#56) of five sampled residents for uneccessary medicat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor one (#56) of five sampled residents for uneccessary medications.
The Resident Census and Conditions of Residents report documented 14 residents were taking an antipsychotic medication.
Findings:
Res #56 was re-admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance.
A care plan, dated 01/25/23, contained no documentation of revision to monitor for side effects of the medication.
A physician order, dated 03/14/23, documented Olanzapine (an anti-psychotic medication) 2.5mg daily in the mornings.
There was no documentation of side effect monitoring found in the medical record.
On 03/29/23 at 9:18 a.m., MDS #1 was asked if the resident care plan should have been revised for the anti-psychotic medication. She reported yes it should have already been done.
On 03/30/23 at 12:42 p.m., the DON reported the medication should have been monitored for side effects.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined the facility failed to ensure:
a. medications were labeled and
b. expired mediations were removed from the medication storage room.
This had the...
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Based on observation and interview, it was determined the facility failed to ensure:
a. medications were labeled and
b. expired mediations were removed from the medication storage room.
This had the potential to affect all 78 residents who resided in the facility.
Findings:
On 03/30/23 at 8:17 a.m., a tour of the medication storage room was conducted with the ADON.
The following medications were found with no label or direction for administration:
a. one bottle of Acidophilus with Pectin Probiotic, and
b. three acetaminophen suppositories 650mg.
The following expired medications were found:
a. three acetaminophen suppositories 650mg with an expiration date 02/04/23,
b. one multi-dose vial of Tuberculin Purified Protein with no open date on the bottle or box, and
c. two multi-dose vial of Influenza vaccine with no open date on the bottle or box.
On 03/30/23 at 8:25 a.m., the ADON was asked if the expired medications should have already been removed. She stated, Yes. The ADON was asked if all the medications were supposed to be labeled. She stated, Yes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide food that accommodated resident allergies for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide food that accommodated resident allergies for one (#17) of two residents reviewed for dining.
The Resident Census and Conditions of Residents documented 76 residents received services from the kitchen.
Findings:
A physician order, dated 03/28/21, documented Res #17 was to receive a regular diet with regular texture. The order did not document the resident's allergy. The EHR documented the resident's allergies were onions and Betadine.
An emergency room visit summary, dated 04/21/21, documented Res #17 was seen for an allergic reaction. The summary documented a diagnosis of food allergy.
A quarterly MDS, dated [DATE], documented Res #17 was cognitively intact and was independent with eating.
A menu for 03/26/23 through 04/01/23, documented the dinner for Sunday 03/26/22 included onion rings.
On 03/27/23 at 12:40 p.m., Res #17 stated he was allergic to onions and had received them on his meal tray at times. He reported having received onion rings last night (03/26) on a hall tray for dinner but he did not eat them. He stated the kitchen staff usually ensure no onions were in his meals when he eats in the dining room but sometimes forgets to remove them from food items served on the hall trays.
On 03/29/23 at 7:30 a.m., Res #17 was observed in the dining room eating. Staff were observed assisting other residents. Res #17's plate did not contain onions. Res #17's meal card was observed to document his allergy to onions in large print.
On 03/29/23 at 8:00 a.m., the DM stated she was aware of Res #17's allergy and did not serve him onions. She could not confirm if the resident was served onions on 03/26/23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure residents were free from physical restraints f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure residents were free from physical restraints for one (#7) of three residents reviewed for physical restraints.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
Res #7 had diagnoses which included arthritis.
An annual MDS, dated [DATE], documented Res #7 was moderately cognitively impaired, was independent with ADLs, and used a rollator walker for mobility.
On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bed rail was raised on both sides of the head of the bed, and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them.
On 03/28/23 at 1:07 p.m., Res #7 was observed in bed with a bed rail raised at the head of the bed and middle of the bed facing the middle of the room.
On 03/28/23 at 1:34 p.m., RA #2 stated she was unsure why Res #7 had bed rails, but possibly because she could get out of bed. RA #2 was then observed lowering both rails.
On 03/28/23 at 1:50 p.m., RN #1 stated the side rails had always been there and she had never questioned their use. RN #1 stated there was no side rail assessment, physician order, or consent in Res #7's chart.
On 03/28/23 at 2:24 p.m., the ADON stated Res #7 did not need side rails for positioning or mobility. She stated the bed rails were a restraint for Res #7.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to review and revise a care plan for two (#45 and #56) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to review and revise a care plan for two (#45 and #56) of 24 sampled residents whose care plans were reviewed.
The Residents Census and Conditions of Residents report documented 78 residents resided in the facility.
Findings:
1. Res #45 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and unspecified glaucoma.
Incident reports, dated 12/21/22, 01/25/23, 02/06/23, 02/25/23, 02/26/23, and 03/09/23 documented resident falls. The reports documented interventions were put in place. The care plan was not revised with the falls and interventions.
A care plan, dated 03/09/23, documented the last revision for falls was 12/01/22.
An incident report, dated 03/18/23, documented the resident had a fall and an intervention was put in place. The care plan was not revised.
On 03/28/23 at 1:55 p.m., MDS #1 was asked if the resident's care plan was reviewed and revised after each fall. They reported they would have to go check and see. They reported there was an issue but that they were working on fixing it.
On 03/28/23 at 3:05 p.m., MDS #1 reported all the falls were not care planned and they should have already been done.
2. Res #56 had diagnoses of dementia with behavioral disturbance.
A physician order, dated 03/14/23, documented to administer Olanzapine (an anti-psychotic medication) 2.5mg daily in the mornings.
Res #56's care plan did not include to monitor for side effects of the anti-psychotic medication.
On 03/29/23 at 9:18 a.m., MDS #1 was asked if the resident care plan should have been revised for the anti-psychotic medication. She reported it should have already been done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation of bedrails for three (#7, 35, #55) of three residents reviewed for bed rails.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
1. Res #7 had diagnoses which included arthritis.
An annual MDS, dated [DATE], documented Res #7 was moderately cognitively impaired, was independent with ADLs, and used a rollator walker for mobility.
On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bedrail was raised on both sides of the head of the bed and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them.
On 03/28/23 at 1:07 p.m., Res #7 was observed in bed with a bed rail raised at the head of the bed and one in the middle of the bed facing the middle of the room.
On 03/28/23 at 1:34 p.m., RA #2 stated she was unsure why Res #7 had bed rails, but possibly because she could get out of bed. RA #2 was then observed lowering both rails.
On 03/28/23 at 1:50 p.m., RN #1 stated the side rails had always been there, and she had never questioned their use. RN #1 stated there was no side rail assessment, physician order, or consent in Res #7's chart.
On 03/28/23 at 2:24 p.m., the ADON stated Res #7 does not need side rails for positioning or mobility.
2. Res #35 had diagnoses which included fracture of left hip and osteoporosis.
An admission MDS, dated [DATE], documented Res #35 was cognitively intact, and required extensive assistance of two staff for bed mobility and transfers.
On 03/27/23, at 1:10 p.m., Res #35 was observed in bed. The bed was observed to have two half rails raised at the head of the bed, and two half rails raised in the middle of the bed. Res #35 stated they required staff assistance to transfer from the bed and utilized the top rails to assist with bed mobility.
On 03/28/23, at 6:57 a.m., Res #35 was observed in bed with four side rails raised.
On 03/28/23 at 1:07 p.m., Res #35 was observed in bed with the top two bed rails raised.
On 03/28/23 at 1:35 p.m., RA #1 stated she was unsure why Res #35 had bed rails.
On 03/28/23 at 1:51 p.m., RN #1 stated the side rails had always been there, and she had never questioned their use. RN #1 stated there was no side rail assessment, physician order, or consent in Res #35's chart.
On 03/28/23, at 2:24 p.m., the ADON stated she was unsure why Res #35 had bedrails. She stated Res #35 did not have a bedrail assessment, consent, or physician order.
3. Res #55 had diagnoses which included dementia and seizure disorder.
A quarterly MDS, dated [DATE], documented Res #55 was cognitively intact, and required extensive assistance of two staff for bed mobility and transfers.
On 03/27/23, at 11:44 a.m., Res #55 was observed in a wheelchair in the resident's room. Res #35's bed was observed pushed against the wall, with two rails raised at the head of the bed, and one rail raised in the middle of the bed facing the resident's room. The resident stated they required assistance from staff to transfer out of the bed.
On 03/28/23, at 1:07 p.m., Res #55 was observed in bed with two rails raised at the head of the bed. The middle rail was lowered.
On 03/28/23 at 1:30 p.m., CNA #1 stated she did not know why Res #55 had bed rails.
On 03/28/23 at 1:52 p.m., RN #1 stated the side rails had always been there, and she had never questioned their use. RN #1 stated there was no side rail assessment, physician order, or consent in Res #35's chart.
On 03/28/23 at 2:24 p.m., the ADON stated she was unsure why Res #55 had side rails raised, but it was possibly for bed mobility. The ADON stated there was no consent, assessment, or physician order in the resident's chart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure:
a. GDR declinations from the physician included a rationale...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure:
a. GDR declinations from the physician included a rationale for one (#6) of five residents reviewed for unnecessary medications and
b. GDR requests were reviewed by the physician for one (#21) of five residents reviewed for unnecessary medications.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
1. Res #6 had diagnoses which included depression and anxiety.
A physician order, dated 05/09/22, documented to administer sertraline 25 mg at bedtime for depression.
A physician order, dated 05/09/22, documented to administer Remeron 15 mg at bedtime for poor appetite.
A pharmacist monthly review GDR request, dated 06/27/22, documented a request to reduce Res #6's Remeron and sertraline. The pharmacist review read in part, .justification for NOT reducing a Psychoactive must be DOCUMENTED either on this form or within the clinical record in order to be considered clinically contraindicated as to why the reduction is not desired at this time . The GDR request was signed as declined by the physician on 07/07/22. The physician did not document a rationale for the declination on the GDR form. A rationale was not documented in the resident's clinical record.
A pharmacist monthly review GDR request, dated 02/20/23, documented a request to reduce Res #6's sertraline. The pharmacist review GDR request was signed as declined by the physician on 03/13/23. The form documented .justification for NOT reducing a Psychoactive must be DOCUMENTED either on this form or within the clinical record in order to be considered clinically contraindicated as to why the reduction is not desired at this time . The physician did not document a rationale for the declination on the GDR form. A rationale was not documented in the resident's clinical record.
A quarterly MDS, dated [DATE], documented Res #6 was cognitively intact and received an antidepressant medication seven out of seven days during the review period.
On 03/29/23 at 3:23 p.m., the DON stated there was no documented clinical rationale on the June 2022 and February 2023 GDR requests. She stated the physician must document a rationale for declining a GDR request.
2. Res #21 had diagnoses which included depression and anxiety.
An undated facility policy, titled Medication Regimen Review, read in part, .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities .
A physician order, dated 11/29/22, documented to administer Remeron 15 mg at bedtime for depression.
A physician order, dated 11/29/22, documented to administer trazodone 150 mg at bedtime for depression.
A physician order, dated 01/16/23, documented to administer clonazepam 0.5 mg two times a day for anxiety.
A significant change MDS, dated [DATE], documented Res #21 was cognitively intact, and received an antianxiety and antidepressant medication seven out of seven days during the review period.
A pharmacy GDR request, dated 02/20/23, requested to decrease Res #21's clonazepam, Remeron, and trazodone. A response to the GDR request was not documented.
On 03/29/23 at 1:13 p.m., the DON stated she was unable to find a response for this GDR request. She stated the response had been re-faxed to the provider. She stated the physician was supposed to respond within 30 days.
On 03/30/23 at 8:06 a.m., the DON provided a copy of the GDR signed by the physician on 03/30/23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to ensure medication error rate was less than 5% for two (#50, #56) of five residents observed during medication pass. A total o...
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Based on record review, observation, and interview, the facility failed to ensure medication error rate was less than 5% for two (#50, #56) of five residents observed during medication pass. A total of 26 opportunities were observed with three errors. Total error rate was (7.6%)
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
1. A physician order for Res #50, dated 01/15/23, documented to administer loratadine 10 mg daily for allergies.
On 03/30/23 at 8:38 a.m., LPN #3 was observed during medication pass. The LPN was observed administering four medications. The medications in the cup did not include the loratadine 10 mg.
On 03/30/23 at 10:56 a.m., LPN #3 denied omitting the medication.
On 03/30/23, at 11:03 a.m., the DON stated staff passing medications were to check the medication card with the order on the EHR before administering the medication.
2. A physician order for Res #56, dated 01/06/23, documented to administer citalopram 20 mg in the morning.
A physician order, dated 03/13/23, documented to discontinue the citalopram 20 mg.
On 03/30/23, at 8:38 a.m., LPN #3 was observed during medication pass. The LPN was observed to administer citalopram 20 mg to the resident.
On 03/30/23, at 10:56 a.m., LPN #3 denied administering the medication. She stated she did not check the cart for discontinued medications since she did not usually pass medications.
On 03/30/23, at 11:03 a.m., the DON stated staff passing medications were to check the medication card with the order on the EHR before administering the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure:
a. the kitchen was clean and maintained in good repair,
b. food was stored in a sanitary manner,
c. the kitchen was free of pest, an...
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Based on observation and interview, the facility failed to ensure:
a. the kitchen was clean and maintained in good repair,
b. food was stored in a sanitary manner,
c. the kitchen was free of pest, and
d. food products were properly labeled/identified.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
On 03/27/23 at 10:20 a.m., a tour of the kitchen was conducted. The dishwashing area had dirty dishes piled up on the table. Dish detergent and boxes of cleaner were observed sitting on the floor. The dishwashing sink would not turn off completely and was constantly running. A leak was observed in one of the hoses under the sink and leaking on the floor. The floor was observed to have a lot of dirt and calcium build up on it. There was trash and a coffee cup observed on the floor. The white tile wall behind the sink was covered in a brown substance and there was a live spider on the wall. Several live roaches were observed on the floor and on the walls.
Metal shelves containing clean dishes was observed to have trash and dirt under them. Grease and food particles were observed on the floor behind the fryer. The prep table had a bottle of cleaner sitting on the bottom shelf along with food items. There were dry food storage containers sitting on the same shelf not labeled and covered with dust and dirt. The shelf next to the handwashing sink was observed to have a dirty rag sitting under a bottle of syrup. The floor in front of the oven had food particles on it. The handwashing sink leaked under the left side of the sink. The staff reported that they do not use that side because of the leak.
Refrigerator #1 contained a metal container of a purple substance that was not covered or dated and a large container of soup was not dated or labeled. There were two packages of an unknown meat substance not dated or labeled. [NAME] #1 reported they do not know how long it has been in there or exactly what it is. The dry storage room contained a large bag of Panko bread crumbs opened to air and bread crumbs on the floor in front and under the bag.
On 03/28/23 at 8:45 a.m., the dietary manager was made aware of the observations made by surveyor during the tours of the kitchen. The DM reported that she told maintenance about the dishwashing sink not turning off completely yesterday and again this morning. She reported that he said he would fix it. The DM was asked about the leak under the handwashing sink. She reported she would put a work order in for it.
On 03/29/23 at 7:24 a.m., dietary aide #1 was asked how long the dishwashing sink had been broken. She reported at least 1-2 months. She reported it had been reported to maintenance several times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to conduct regular inspections of all bed rails as part of a regular maintenance program for three (#7, 35, #55) of three residents reviewed for...
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Based on observation and interview, the facility failed to conduct regular inspections of all bed rails as part of a regular maintenance program for three (#7, 35, #55) of three residents reviewed for bedrails.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bedrail was raised on both sides of the head of the bed, and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them.
On 03/27/23, at 11:44 a.m., Res #55 was observed in a wheelchair in the resident's room. Res #35's bed was observed pushed against the wall, with two rails raised at the head of the bed, and one rail raised in the middle of the bed facing the resident's room. The resident stated they required assistance from staff to transfer out of the bed.
On 03/27/23, at 1:10 p.m., Res #35 was observed in bed. The bed was observed to have two half rails raised at the head of the bed, and two half rails raised in the middle of the bed. Res #35 stated they required staff assistance to transfer from the bed and utilized the top rails to assist with bed mobility.
On 03/30/23 at 12:20 p.m., the maintenance supervisor stated he did not regularly inspect the bed or bed rails. He stated the only reason he would inspect a bed or bed rails is if a work order was submitted for a repair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, it was determined the facility failed to provide a safe, clean, sanitary, homelike environment. The facility failed to ensure:
a. a shower room was c...
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Based on record review, observation and interview, it was determined the facility failed to provide a safe, clean, sanitary, homelike environment. The facility failed to ensure:
a. a shower room was clean and in working order and
b. the laundry was free of dirt and dust.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
On 03/29/23 at 9:45 a.m., the ADON was asked how long the south hall shower room had been broken. She reported a year or less.
On 03/29/23 at 9:47 a.m., the south hall shower room was observed to have mold in the shower stall on the right, with water constantly running out of the shower head. There was mold observed on all the tiles in this shower. The maintenance supervisor reported he had been storing his stuff in this room since it is not working. The maintenance supervisor was asked how long this shower had been out of order. He reported not very long. He was asked if the water has been running this entire time. He replied, Yes.
On 3/30/23 at 8:30 a.m., a tour of laundry facility with laundry staff #1 was conducted. The hand washing sink was observed to have dirt and dust on the top of the sink on both sides. There was a black rubber bowl sitting under the sink with a large amount of dust covering it. There was a one gallon paint can sitting under the sink area that was covered in dust.
The back of the washers contained a lot of dust covering the hoses and wall. The electrical boxes behind the washers had dust observed on them, and the top of the washers had a small amount of dust on them. The dryers were observed to have a large amount of dust between them. The air conditioning vent had large amount of dust on the cover and the filter had a large amount of dust covering it.
On 3/30/23 at 8:40 a.m., Laundry staff #1 reported that she just started in February 2023 and the main laundry lady had been out and was supposed to be back next week. She reported she would ask about the proper cleaning process. There was a cleaning schedule observed hanging on the wall to wipe machines down after each shift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side.
The Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side.
The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
Findings:
On 03/29/23 at 2:33 p.m., a hand rail on the 300 hall between the shower room and room [ROOM NUMBER] was observed to be loose and easily moved up and down. A hand rail between room [ROOM NUMBER] and room [ROOM NUMBER] was loose, easily moved up and down and tilted downward on the right side.
On 03/30/23 at 7:33 a.m., a handrail between 200 and 300 hall on the left side next to the exit door was observed to be loose and easily moved up and down.
On 03/30/23 at 8:28 a.m., the maintenance supervisor stated he was aware of loose hand rails and had not had time to get to them yet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to maintain an effective pest control program.
The Resident Census and Conditions of Residents documented 78 residents resided ...
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Based on record review, observation, and interview, the facility failed to maintain an effective pest control program.
The Resident Census and Conditions of Residents documented 78 residents resided in the facility.
Findings:
On 03/27/23 at 10:20 a.m., during the initial tour of the kitchen there were multiple live roaches observed in the dishwashing area of the kitchen. There were live roaches crawling on the walls and floors. There was a live roach observed under the handwashing sink crawling on the wall.
On 03/28/23 at 8:45 a.m., during a second tour of the kitchen there were live roaches in the dishwashing area crawling on the walls.
On 03/29/23 at 2:30 p.m., the maintenance supervisor reported they had the facility treated for pest twice a month.
Record review of pest control receipts documented the kitchen was treated for pests twice a month.
Mar 2019
2 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's family was notified of a resident's change in condition for one (#6) of 19 resident's w...
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Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's family was notified of a resident's change in condition for one (#6) of 19 resident's whose records were reviewed for notification of a change in condition. The administrator identified 71 residents resided in the faciltiy. Findings:
Resident #6 had diagnoses which included depression. The resident no longer resided in the facility.
A nurse's note, dated 11/13/18 at 3:55 p.m., documented the resident was seen by the physician for a mass on the left side of his neck. The note documented the physician ordered a CAT scan of the neck and a referral to the dermatologist for a skin lesion.
A nurse's note, dated 11/13/18 at 3:59 p.m., documented the resident's daughter was called to notify her of the resident's new orders but the phone number listed was no longer a working number.
A nurse's note, dated 11/15/18 at 2:26 p.m., documented the resident was out of the facility for a CAT scan and blood work and returned with no new orders.
A nurse's note, dated 11/15/18 at 4:09 p.m., documented the facility nurse had been contacted by the physician's office. The note documented the resident did not have a mass on the left side of his neck but did have a blood clot on his lung and the physician wanted the resident to start receiving Eliquis 5 milligrams two times a day. The note documented the facility tried to contact the resident's daughter and her husband three times but the phone number was disconnected. The note documented they would continue to try to contact the resident's power of attorney.
There was no documentation to show the resident's daughter was notified of the resident's change in condition once the daughter had given the facility the updated phone number.
A nurse's note, dated 12/12/18 at 12:38 p.m., documented the resident had redness, swelling, and yellow drainage to the right eye. The note documented the physician was notified.
There was no documentation to show the resident's daughter was notified of the resident's change in condition.
A weight change note, dated 12/13/18 at 1:04 p.m., documented the resident received an order to discontinue Prozac and to start Remeron 15 milligrams at bedtime.
There was no documentation to show the resident's daughter was notified of the resident's change in condition.
A progress note, dated 01/31/19 at 1:02 p.m., documented the resident had been seen by dermatology for a biopsy of his left neck and cheek. The note documented the resident received three sutures in his neck and one in his check. The note documented Vaseline was to be applied to the site two times a day and follow up in seven days. The note documented a message was left for the resident's daughter.
A nurse's note, dated 01/31/19 at 2:42 p.m., documented the resident's daughter was notified of the resident's appointment today and that he received sutures.
A quarterly assessment, dated 02/28/19, documented the resident was severely impaired cognitively.
A nurse's note, dated 03/03/19 at 12:59 p.m., documented the resident had a blister on his left heel. The note documented the resident had an order to place sure prep to both heels. The note documented the resident's heels should be floated and heel protectors should be applied.
There was no documentation to show the resident's daughter was notified of the resident's change in condition.
On 03/19/19 at 12:41 p.m., LPN #1 was asked about the resident's daughter's number being out of order. She stated the resident's daughter had told her in November or December of 2018 that her husband's identity had been stolen and they had to change all of their numbers. She stated she had updated the resident's record with the new number herself. She stated she could not really remember exactly when she had put the new number in the resident's record.
At 1:31 p.m., LPN #1 was asked when she would notify a resident's family if there was a change in condition. She stated she would notify family if the resident had anything out of the ordinary.
On 03/20/19 at 12:05 p.m., the director of nursing was asked if the resident's family had been notified about the resident's changes after the facility received their new number. She stated someone should have called the resident's daughter as soon as they had a working number and it had not been done.
MINOR
(C)
Minor Issue - procedural, no safety impact
Infection Control
(Tag F0880)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, it was determined the facility failed to ensure cross contamination did not occur in the laundry room. The administrator identified 71 residents who...
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Based on observation, interview, and record review, it was determined the facility failed to ensure cross contamination did not occur in the laundry room. The administrator identified 71 residents who resided in the facility. Findings:
On 03/19/19 at 10:14 a.m. a tour of the laundry room was completed. On the left side of the room as you entered the laundry room, there was a metal table with clean linen laying on the table. Right across from the table were the washers. There was a distance of approximately 4 to 5 feet which separated the washers and the table. A rolling barrel of soiled linen sitting in front of the washer would be within approximately two feet from the table which had clean laundry on it. As you walk on through the area with the washers a row of dryers were along the back wall. There was only one entrance and exit out of the laundry room.
At 10:20 a.m., the laundry supervisor was asked about cross contamination in the laundry room. She stated she tried to keep from contaminating the clean clothes with the dirty cloths right across from them. She stated there was really no way to prevent it because there was only one entrance and exit in the laundry room.
At 10:30 a.m., the administrator was asked to tour the laundry room. He stated he could see how cross contamination could occur and he would be calling someone right away to look at the situation and decide how it could be fixed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $24,850 in fines. Higher than 94% of Oklahoma facilities, suggesting repeated compliance issues.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Heartsworth Center For Nursing & Rehabilitation's CMS Rating?
CMS assigns Heartsworth Center For Nursing & Rehabilitation an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oklahoma, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Heartsworth Center For Nursing & Rehabilitation Staffed?
CMS rates Heartsworth Center For Nursing & Rehabilitation's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 55%, compared to the Oklahoma average of 46%.
What Have Inspectors Found at Heartsworth Center For Nursing & Rehabilitation?
State health inspectors documented 33 deficiencies at Heartsworth Center For Nursing & Rehabilitation during 2019 to 2024. These included: 32 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Heartsworth Center For Nursing & Rehabilitation?
Heartsworth Center For Nursing & Rehabilitation is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by RIVERS EDGE OPERATIONS, a chain that manages multiple nursing homes. With 146 certified beds and approximately 67 residents (about 46% occupancy), it is a mid-sized facility located in Vinita, Oklahoma.
How Does Heartsworth Center For Nursing & Rehabilitation Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, Heartsworth Center For Nursing & Rehabilitation's overall rating (1 stars) is below the state average of 2.6, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Heartsworth Center For Nursing & Rehabilitation?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Heartsworth Center For Nursing & Rehabilitation Safe?
Based on CMS inspection data, Heartsworth Center For Nursing & Rehabilitation has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Heartsworth Center For Nursing & Rehabilitation Stick Around?
Heartsworth Center For Nursing & Rehabilitation has a staff turnover rate of 55%, which is 9 percentage points above the Oklahoma average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Heartsworth Center For Nursing & Rehabilitation Ever Fined?
Heartsworth Center For Nursing & Rehabilitation has been fined $24,850 across 1 penalty action. This is below the Oklahoma average of $33,327. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Heartsworth Center For Nursing & Rehabilitation on Any Federal Watch List?
Heartsworth Center For Nursing & Rehabilitation is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.