Below average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartsworth Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with a full code status was found unresponsive and did not receive CPR because an LPN incorrectly assumed the resident was a DNR due to hospice involvement. The LPN instructed CNAs to clean the body without verifying code status or calling a code, and no resuscitation efforts were made despite the resident's documented wishes and facility policy.
A cook was observed using a food thermometer to check multiple food items, wiping it with the same towel between uses instead of properly sanitizing it as required by facility policy. The Dietary Manager confirmed that the thermometer should have been sanitized with an alcohol pad between uses.
An oxygen cylinder was observed upright and unsecured next to a resident's bed, contrary to facility policy requiring secure storage. Staff interviews confirmed that oxygen cylinders should be attached to appropriate holders or carriers, and at the time, multiple residents were using supplementary oxygen.
The facility failed to include a focus on wandering in the care plan for a resident with recurrent depressive disorder who exhibited wandering behavior. Despite multiple progress notes and a high-risk assessment for wandering, the care plan only addressed falls and did not adequately cover the resident's wandering behavior. Staff interviews confirmed the oversight, and the DON acknowledged issues with the care plan system.
The facility failed to serve foods at a palatable temperature from one of its kitchen service areas, affecting 40 residents. Observations revealed that the steam table was not producing steam and was only warm to the touch, with food temperatures recorded below the required 135 degrees Fahrenheit. The issue was reported to maintenance, but the dietary manager admitted that holding temperatures were not measured throughout the meal service.
The facility failed to provide three substantive meals daily to its residents. While the policy required three meals, the schedule showed breakfast, brunch, and supper with snack carts throughout the day. Staff confirmed that most residents received a continental breakfast, not a substantial meal, and only the skilled unit received a hot breakfast. This inconsistency led to the deficiency.
The facility failed to maintain the physical environment of the main kitchen and serve cold foods in a sanitary manner in the satellite dining room. The main kitchen lacked a dedicated handwashing sink, had structural issues, and the satellite kitchen also lacked a handwashing sink. Nursing staff were observed serving cold foods without sanitizing their hands, and a resident served themselves without washing their hands. The dietary manager and DON acknowledged the issues.
The facility failed to inform residents that signing binding arbitration agreements was not a condition for admission or continued care. The agreements also lacked explicit acknowledgment of understanding and included the name of an unrelated nursing facility. Two residents signed these agreements without proper information or acknowledgment.
The facility failed to assist a resident with their meal in a dignified manner. Staff were observed standing beside the resident and conversing with other staff, contrary to the facility's policy and the DON's expectations.
The facility failed to educate a resident about advance directives and did not offer the opportunity to create or decline one. The resident's EMR lacked documentation of an advance directive, and although there was a full code order, there was no record of discussion with the resident or their representative.
The facility failed to provide privacy for a resident by placing a camera in their room without proper documentation or consent. The camera's monitor was visible to other residents, visitors, and staff, and the facility lacked a policy for camera use. The resident's care plan did not address the camera, and there was no record of the resident being notified or agreeing to its use.
The facility failed to ensure the accuracy of a baseline care plan for a resident with hypertension and anemia. The care plan incorrectly documented a pressure ulcer upon admission, while an admission skin assessment showed normal skin with no new wounds. The ADON was unaware of any skin issues, and the MDS coordinator acknowledged the inaccuracy. The DON stated they were responsible for the accuracy of baseline care plans.
The facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for a resident. The incorrect dosage documentation may have influenced the physician's decision to reduce the medication. Additionally, the facility identified an issue with floor nurses not reconciling or confirming orders with the physician once a resident returned from the hospital.
The facility failed to notify the physician of a wound for a resident with hypertension and anemia. Despite the discovery of an open sore on the resident's right buttocks, the LPN did not contact the physician, and the wound worsened over time. Both the ADON and DON confirmed that the physician should have been notified immediately.
The facility failed to secure the medication room, which was found propped open with a chair and unattended. An LPN admitted to leaving the door open while preoccupied with a resident being sent to the hospital. The room contained locked medication carts and various resident medications, but no unsecured controlled medications were observed.
The facility failed to ensure lint screens were cleared as recommended for three dryers in the laundry room. A laundry employee reported cleaning the screens every eight hours instead of the recommended four hours. Observations revealed considerable lint buildup on the screens. The maintenance supervisor confirmed that laundry employees were responsible for cleaning the lint screens.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when a resident with a documented full code status was not provided cardiopulmonary resuscitation (CPR) after being found unresponsive. The resident, who was cognitively intact and had a physician's order for full code, was discovered in their room by a CNA who reported the situation to an LPN. The LPN checked the resident's blood pressure, declared the resident dead, and instructed the CNA to clean the body without initiating a code or attempting CPR. No code was called, and no CPR was performed, despite the resident's full code status. The CNAs involved did not verify the resident's code status before proceeding with post-mortem care. One CNA assumed that because CPR had not been performed, the resident must have had a Do Not Resuscitate (DNR) order. Both CNAs described the resident's body as limp, with no significant discoloration or stiffness, and noted the presence of vomit and some blood. The LPN did not check the code status before instructing the CNAs to clean the body and later stated they believed the resident was on hospice and had a DNR order. The Assistant Director of Nursing (ADON) learned of the death via text message from the LPN and subsequently discovered that the resident was, in fact, a full code and not on hospice with a DNR. The ADON confirmed with the hospice service that there was no DNR in place. The failure to verify the resident's code status and to initiate CPR as required by facility policy and the resident's documented wishes led to the deficiency.
Removal Plan
- Facility QAPI members met to discuss the event, root cause, implementation of interventions, and auditing/compliance tools.
- DNR Binders are located at each nurse's station in the instance PCC is down for any reason.
- The ADON is responsible to update the binder for new admissions.
- The DON conducted chart audits regarding code status to ensure accuracy.
- The nurse was suspended pending further investigation and later terminated.
- Monitoring will be accomplished by the DON and/or designee auditing code status to ensure compliance.
- Any resident death that occurs in the facility will be reviewed to be sure code status was followed correctly.
Failure to Sanitize Food Thermometer Between Uses in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitization of kitchen equipment, specifically food thermometers, during meal preparation for 70 residents. On observation, a cook was seen recording food temperatures by inserting a thermometer into multiple food containers, including Brussel sprouts, sweet potatoes, and sliced ham, wiping the thermometer with the same towel between each use rather than sanitizing it appropriately. The facility's policy requires all equipment and food contact surfaces to be cleaned and sanitized using heat or chemical sanitizing solutions. The Dietary Manager confirmed that the thermometer should have been sanitized between uses with an alcohol pad.
Unsecured Oxygen Cylinder Found in Resident Room
Penalty
Summary
The facility failed to ensure that oxygen cylinders were stored securely, as required by their own policy and standard safety practices. During an observation, an oxygen cylinder was found upright and unsecured next to the head of a resident's bed. The facility's policy specifies that small-sized oxygen cylinders must be attached to a cylinder stand or to medical equipment designed to hold them. Interviews with staff, including a CNA, an LPN, and the ADON, confirmed that oxygen cylinders should not be left unsecured in resident rooms and should be stored in appropriate carriers or holders. At the time of the deficiency, 19 residents in the facility were utilizing supplementary oxygen.
Failure to Address Wandering in Care Plan
Penalty
Summary
The facility failed to include a focus on wandering in the comprehensive care plan for a resident diagnosed with recurrent depressive disorder, who exhibited wandering behavior. Despite multiple progress notes documenting the resident's wandering and attempts to enter other residents' rooms, the care plan did not address this behavior. The facility's policy on elopements and wandering residents mandates that such behaviors be included in the care plan, but this was not done for the resident in question. The resident's wandering was noted on several occasions, including attempts to enter the kitchen and other residents' rooms, and the resident was assessed as high risk for wandering based on the facility's Wandering Risk Scale. However, the care plan only included a focus on falls, which did not adequately address the wandering behavior. Interviews with facility staff, including the ADON, CNA, LPN, and MDS Coordinator, confirmed that the resident did wander and that the care plan should have included a focus on wandering. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the resident's wandering behavior based on the documentation in the medical record. The DON admitted that the care plan system at the facility was broken and that facility leadership would need to work on fixing it, emphasizing the need for every IDT member to be involved in care plan meetings.
Failure to Maintain Palatable Food Temperatures
Penalty
Summary
The facility failed to serve foods at a palatable temperature from one of its two kitchen service areas, affecting 40 residents who ate meals served from the satellite kitchen. Observations revealed that the steam table in the satellite kitchen was not producing steam and was only warm to the touch. The holding temperatures of the sausage patties and soup were recorded at 94 degrees Fahrenheit and 118 degrees Fahrenheit, respectively, which are below the required holding temperature of at least 135 degrees Fahrenheit. Cook #1 was unaware of the correct holding temperature for hot foods and noted that the steam table had been turned on since 7:00 a.m. but was not hot enough due to a malfunctioning burner and low water level in the steam table reservoir. Cook #2 confirmed the issue and stated that they had reported the problem to the maintenance department the previous week. The dietary manager confirmed that the holding temperature for hot food should be greater than 135 degrees Fahrenheit and stated that food temperatures were measured before sending food from the main kitchen to the satellite kitchen and again immediately after placing the food on the steam table. However, the dietary manager admitted that they did not measure the holding temperature of the food during the entirety of the meal service, which would provide a more accurate measurement of the food's temperature throughout the service period. This oversight contributed to the failure to maintain the required holding temperature for hot foods, resulting in the deficiency noted in the report.
Failure to Provide Three Substantive Meals Daily
Penalty
Summary
The facility failed to ensure that three substantive meals were served daily to its residents. According to the facility's policy, each resident should receive at least three meals daily at times comparable to typical mealtimes in the community or in accordance with resident needs, preferences, requests, and the plan of care. However, the facility's meal schedule showed that breakfast was served at 7:30 am, brunch at 10:30 am, and supper at 4:30 pm, with snack carts provided at various times throughout the day. Interviews with staff revealed that the breakfast served to most residents was a continental breakfast consisting of pastries, cold cereal, oatmeal, or yogurt, which was not considered a substantial meal by the staff. Only residents on the skilled unit received a hot breakfast, and other residents had to request it if they wanted a hot meal, but it was not offered to them proactively. The Assistant Director of Nursing (ADON) reported that 73 residents received meals from the kitchen. Staff members, including a Certified Medication Aide (CMA) and a Licensed Practical Nurse (LPN), confirmed that the breakfast provided was more of a snack than a meal. The Dietary Manager (DM) also stated that a hot breakfast was served on the skilled unit, but other residents were served a continental breakfast. This inconsistency in meal provision led to the deficiency, as the facility did not meet the requirement of serving three substantive meals daily to all residents, thereby failing to adhere to their own policy and the needs and preferences of the residents.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain the physical environment of the main kitchen and serve cold foods in a sanitary manner in the satellite dining room. Observations revealed that the main kitchen lacked a dedicated handwashing sink, and staff were using a two-compartment sink for handwashing, which was also used for food preparation. The kitchen had several structural issues, including missing and broken baseboards, holes in the ceiling, rusted air vents and lighting fixtures, water stains, peeling paint, and unsecured equipment. The satellite kitchen also lacked a handwashing sink, requiring staff to use a sink located on the opposite side of the dining room. Nursing staff were observed serving cold foods in the satellite dining room without sanitizing their hands, and a resident was seen serving themselves without washing their hands. The dietary manager and the Director of Nursing (DON) acknowledged the issues, with the dietary manager noting that the ceiling damage predated their employment and the administrator explaining that a pipe burst had caused the damage. The administrator also confirmed that there had never been dedicated handwashing sinks in the main or satellite kitchens.
Failure to Properly Inform Residents About Binding Arbitration Agreements
Penalty
Summary
The facility failed to provide residents with binding arbitration agreements that clearly informed them of their right not to sign the agreement as a condition of admission or continued care. Additionally, the agreements did not include an explicit acknowledgment by the residents or their representatives that they understood the provisions of the agreement. The agreements also erroneously included the name of a second nursing facility, which the residents were not aware of. This deficiency was identified for two residents, who had signed the agreements without being properly informed or acknowledging their understanding of the terms. The facility's Social Services Director (SSD) confirmed that the agreements used did not meet the required standards and that there was no policy and procedure related to arbitration agreements at the facility. Resident #50 and Resident #63 both signed the binding arbitration agreements without being informed that signing was not a condition for admission or continued care. Resident #50 did not recall signing the agreement and was unaware of the second nursing facility mentioned in the document. Similarly, Resident #63 did not know what a binding arbitration agreement was and did not recall signing one. The facility's Administrator acknowledged that the current arbitration agreement form was adopted from the previous owners and recognized its shortcomings. The SSD also admitted to being unaware of any policy and procedure related to arbitration agreements at the facility.
Failure to Assist Resident with Meal in a Dignified Manner
Penalty
Summary
The facility failed to assist a resident with their meal in a dignified manner. Specifically, Resident #10, who required total assistance with meals, was observed on multiple occasions being assisted by staff who stood beside them and engaged in conversations with other staff members. This behavior was contrary to the facility's Assistance with Meals policy, which emphasized the importance of feeding residents with attention to dignity, including not standing over residents and minimizing interactions with other staff during meal assistance. On two separate occasions, staff members were observed standing beside Resident #10 while assisting with their meal and conversing with other staff members. Interviews with CNAs revealed that they believed sitting while assisting residents was more sociable and respectful. The DON confirmed that the expectation was for staff to sit down while assisting residents with their meals. Despite this, the observed actions did not align with the facility's policy or the DON's expectations, leading to a deficiency in maintaining the resident's dignity during meal assistance.
Failure to Provide Education and Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide education about advance directives and did not offer an opportunity for a resident to have or decline an advance directive. Specifically, for one of the 24 sampled residents, there was no documentation in the electronic medical record (EMR) of an advance directive. Although there was a physician's order for full code status, there was no paperwork indicating that the code status was discussed with the resident or their representative. The Assistant Director of Nursing (ADON) confirmed the absence of documentation and stated that the resident did not have an advance directive and was not given education on the matter or the opportunity to create one.
Failure to Ensure Resident Privacy with Camera Use
Penalty
Summary
The facility failed to provide privacy for a resident by placing a camera in their room without proper documentation or consent. The resident, who was severely impaired in cognition and experienced acute changes in mental status, had a camera positioned facing their bed. The camera's monitor was placed on a half wall in front of the nurses' station, where it was visible to other residents, visitors, and staff. Despite the resident's difficulty hearing and inability to respond appropriately to questions about the camera, the facility did not have a documented care plan, physician's order, or resident consent for the camera's use as a fall intervention. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lack of documentation and stated that the camera was used as a last resort before employing a private sitter. The ADON confirmed that the resident's care plan did not address the use of the camera, and there was no record of the resident being notified or agreeing to its use. The facility also lacked a policy or procedure for using cameras in residents' rooms, and the monitor was not consistently positioned to ensure privacy, as it was often left facing upward or inward, allowing others to view the resident's activities.
Inaccurate Baseline Care Plan Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a baseline care plan for a resident diagnosed with hypertension and anemia. The baseline care plan, dated 04/17/24, incorrectly documented that the resident had a pressure ulcer upon admission. However, an admission skin assessment conducted on the same date indicated that the resident had normal skin with good elasticity and no new wounds. The ADON was unaware of any skin issues at the time of admission, and the MDS coordinator responsible for the baseline care plan acknowledged the inaccuracy. The DON stated that they were ultimately responsible for ensuring the accuracy of baseline care plans.
Incorrect Dosage Documentation by Pharmacist
Penalty
Summary
The facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for one of five residents whose clinical records were reviewed for unnecessary medications. The physician's order initially documented the resident was to receive Zoloft 200 mg daily. However, the request for a gradual dose reduction incorrectly documented the resident received Zoloft 100 mg daily. Subsequently, the physician's order was written based on this incorrect dosage, reducing the medication to 50 mg daily. The resident was later documented to receive Zoloft 200 mg daily again. The ADON stated that the pharmacist's incorrect documentation may have influenced the physician's decision to reduce the medication. Additionally, the facility identified an issue with floor nurses not reconciling or confirming orders with the physician once a resident returned from the hospital, which was around the same time the resident went to the hospital and returned on the same day.
Failure to Notify Physician of Resident's Wound
Penalty
Summary
The facility failed to notify the physician of a wound for one resident sampled for wounds. The resident, who had diagnoses including hypertension and anemia, was admitted with normal skin and no new wounds as of 04/17/24. However, a nurse note dated 04/28/24 documented an open sore on the resident's right buttocks. Despite this, there was no documentation in the resident's medical record indicating that the physician had been notified about the open area. On 05/01/24, an LPN acknowledged awareness of the sore and stated they had been treating it with barrier cream but had not contacted the physician. The LPN also noted that the area had become larger since they last saw it on 04/29/24. Both the ADON and DON confirmed that the physician should have been notified immediately upon discovering the wound, which did not occur in this case.
Medication Room Left Unsecured and Unattended
Penalty
Summary
The facility failed to ensure the medication room door was secured, as it was found propped open with a chair and unattended. This incident was observed at 6:51 a.m. on 04/30/24, with no staff members present in or near the medication room. The room contained four locked medication carts and various resident medications in bins on shelves. No unsecured controlled medications were observed. LPN #1, who entered the room at 6:55 a.m., confirmed that the door should never be left open and unattended, as it posed a risk of residents accessing medications and potentially harming themselves. LPN #2 later admitted to leaving the medication room door propped open with a chair, explaining that they were preoccupied with a resident being sent to the hospital and did not consider the door. The ADON conducted a search of the medication room and found no missing medications. The DON confirmed that LPN #2 had been counseled about the incident, emphasizing that the medication room must always be secured.
Failure to Clean Lint Screens as Recommended
Penalty
Summary
The facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room. On 04/30/24 at 10:25 am, a laundry employee reported that although the sign on the dryer indicated the lint screen should be cleaned every 4 hours, they only cleaned it every eight hours or so when they were busy. Signs were observed to be affixed to all three dryers in the laundry room, stating the lint screens were to be cleaned every 4 hours. At 10:30 am, the same laundry employee was asked to remove the cover to expose the lint screen on one of the dryers, revealing a considerable amount of lint covering the screen. The employee stated they had not cleaned the lint screens that day but assumed they had been cleaned the previous day. On 05/02/24 at 1:50 pm, the maintenance supervisor stated that laundry employees were responsible for cleaning the lint screen, while maintenance staff were responsible for cleaning the lint around the fire box.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vinita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Healthcare And Rehab | 19.4 mi | ★★★★★ | 0 | 0 |
| Grove Nursing Center | 21.6 mi | ★★★★★ | 0 | 0 |
| Grand Lake Villa | 22.5 mi | ★★★★★ | 0 | 0 |
| Miami Nursing Center, Llc | 22.6 mi | ★★★★★ | 14 | 2 |
| Betty Ann Nursing Center | 22.6 mi | ★★★★★ | 1 | 0 |
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