Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartway At Heritage Village Health And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain RN coverage for 8 consecutive hours, 7 days per week. Review of RN time cards showed multiple days without the required RN coverage, and the administrator stated an agency RN had been scheduled for those days but did not show up and did not notify the facility. The facility had 84 residents.
A resident with atrial fibrillation, anxiety disorder, and recurrent depressive disorder was ordered Seroquel 100 mg at bedtime for anxiety, and the record showed the resident was cognitively intact with a BIMS of 14. The DON confirmed that informed consent for antipsychotic use was not completed, even though the resident was receiving psychotropic medication.
Inappropriate Diagnoses for Antipsychotic Use: The facility failed to ensure appropriate diagnoses for antipsychotic use for two residents. One resident received Seroquel for anxiety despite being cognitively intact, and the DON and pharmacy consultant stated anxiety was not an acceptable diagnosis for antipsychotic use. Another resident received Seroquel for dementia without behavioral, psychotic, or mood disturbances, and the DON stated dementia was not an appropriate diagnosis for antipsychotic use.
Failure to complete quarterly smoking assessments for a resident who smoked tobacco products. A resident was observed smoking in the designated area with staff monitoring, and the record showed an admission smoking assessment and a care plan for supervised smoking. However, there was no documentation of the required quarterly smoking assessments, and the DON stated they believed the assessments were annual and did not know why the quarterly assessment was not completed.
A resident with cognitive impairment and physical care needs was forced by a CNA to use a bedpan instead of the requested bedside commode, resulting in a bruise and emotional distress. The incident was identified as neglect due to the failure to honor the resident's care preferences and provide necessary assistance.
A resident with respiratory issues did not receive adequate care, as the facility failed to document necessary assessments and follow-up after breathing treatments. Nursing staff did not conduct or document respiratory assessments despite the resident's deteriorating condition. Additionally, the facility did not adhere to policies for maintaining respiratory equipment for other residents, contributing to the deficiency.
The facility failed to develop comprehensive care plans for two residents, omitting critical medical needs such as COPD management and oxygen use. One resident's care plan lacked documentation for COPD, while another's did not include their continuous oxygen requirement, despite physician orders and assessments indicating its necessity.
The facility did not comply with food service safety standards by failing to label and date food items. During a kitchen inspection, surveyors found ten plastic cups with various colored liquids that were not labeled or dated, contrary to the facility's policy. The DON confirmed that 68 residents were in the facility at the time.
The facility was found deficient in maintaining a safe and clean environment. Observations revealed an unclean shower room with potential mold and an unlocked janitor closet containing hazardous chemicals. The administrator acknowledged the issues but lacked a documented cleaning schedule, relying on verbal instructions.
A resident with depression was routinely woken up at 4:00 a.m. by staff, despite preferring to wake up at 7:00 a.m. The social services director confirmed that residents were not asked about their preferred wake-up times, leading to a deficiency in honoring resident choice.
A facility failed to use a gait belt during the transfer of a resident with hemiplegia and hemiparesis, contrary to its policy. A CNA was observed lifting the resident from a recliner to a wheelchair without the gait belt, despite acknowledging the requirement to use it. The DON confirmed the gait belt should have been used.
A facility failed to monitor side effects for a resident receiving psychotropic medications, including Sertraline and Risperidone, prescribed for depression. The resident's chart lacked documentation of side effect monitoring, which was confirmed as necessary by the DON.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure RN coverage for eight consecutive hours seven days per week. Record review of RN time cards from July 2025 through January 2026 showed no RN coverage for eight consecutive hours on 08/03/25, 08/17/25, 10/04/25, 10/18/25, 11/29/25, 12/27/25, and 01/04/26. The administrator identified that 84 residents resided in the facility. On 01/07/26 at 4:05 p.m., the administrator stated an agency RN had been scheduled for the listed dates, but nobody showed up and nobody notified the administrator.
Missing Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to complete informed consent for the use of an antipsychotic medication for Resident #17. The resident had diagnoses including atrial fibrillation, anxiety disorder, and recurrent depressive disorder, and the record showed the resident was cognitively intact with a BIMS of 14. The care plan documented psychotropic medication use, and a physician order dated 12/07/25 showed Seroquel 100 mg by mouth at bedtime for anxiety disorder. The admission assessment also showed the resident received antipsychotic, antidepressant, and anticoagulant medications. During record review on 01/07/26, the DON stated that a consent for antipsychotic medication use was not completed and should have been completed.
Inappropriate Diagnoses for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications had an appropriate diagnosis for 2 of 5 sampled residents reviewed for unnecessary medications. The administrator identified 29 residents receiving antipsychotic medication. Facility policy stated that informed consent must be completed and signed before the first dose of any psychotropic medication except in emergency situations. Resident #17 had diagnoses including atrial fibrillation, anxiety disorder, and recurrent depressive disorder. The resident’s care plan showed psychotropic medication use, and a physician order dated 12/07/25 showed Seroquel 100 mg by mouth at bedtime related to anxiety disorder. An admission assessment dated 12/10/25 showed the resident was not cognitively impaired with a BIMS of 14 and that the resident received antipsychotic, antidepressant, and anticoagulant medications. During interview, the DON stated the resident was receiving Seroquel for anxiety and that anxiety was not an appropriate diagnosis for antipsychotic use, and the pharmacy consultant stated the same. Resident #61 had a diagnosis of dementia without behavioral, psychotic, or mood disturbances, and a physician order dated 12/06/24 showed Seroquel 400 mg daily at bedtime for that diagnosis. An annual assessment dated 02/19/25 showed the resident was severely cognitively impaired with a BIMS of 04 and receiving antipsychotic medication. The DON stated dementia was not an appropriate diagnosis for the use of an antipsychotic medication.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to ensure quarterly smoking assessments were completed for one resident who smoked tobacco products. Resident #5 was observed outside smoking in the designated smoking area with staff monitoring. The resident’s record showed a smoking assessment completed on admission and a care plan dated 03/24/25 stating the resident would always smoke in the designated smoking area and that staff would assist the resident to smoking areas and monitor as needed. The facility’s smoking policy required a supervised smoking assessment on all residents who smoke upon admission and quarterly thereafter, but there was no additional documentation of quarterly smoking assessments for Resident #5. During record review, the DON stated they believed smoking assessments were done annually and did not know why the quarterly assessment was not completed for the resident.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
A resident with a history of falls, muscle wasting, atrophy, and moderate cognitive impairment required assistance with personal care and was continent of bowel and bladder. During an incident, the resident was found to have a bruise on their right arm, which was noticed by family members. The resident reported that a CNA was persistent in requiring the use of a bedpan instead of the requested bedside commode, and expressed not wanting that CNA to provide care again. The resident was unaware of how the bruise occurred but stated they were afraid of the CNA involved. Facility records indicate that two CNAs were working on the resident's hall at the time of the incident. The investigation determined that one CNA had forced the resident to use the bedpan against their wishes, failing to provide care as requested by the resident. This action was identified as neglect, as it did not meet the resident's needs and preferences, and resulted in emotional distress and physical harm as evidenced by the bruise.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with new onset respiratory changes, leading to an Immediate Jeopardy situation. The resident, who had diagnoses including congestive heart failure and dementia, experienced shortness of breath and wheezing. Despite a physician ordering a breathing treatment, the facility did not document a comprehensive respiratory assessment, including lung sounds and post-treatment oxygen saturation. Vital signs were inconsistently recorded, and there was no documented follow-up assessment after treatments. The nursing staff did not conduct or document necessary respiratory assessments for the resident, despite being aware of the resident's deteriorating condition. The day shift RN acknowledged the resident's respiratory issues but failed to document a focused assessment. The evening shift RN also did not assess the resident, and the night shift RN discovered the resident had passed away without prior assessment. The Director of Nursing (DON) admitted there was no policy for respiratory assessment, relying instead on general nursing practices. Additionally, the facility did not adhere to its own policies regarding the maintenance of respiratory equipment for other residents. Oxygen tubing and humidifier bottles were not changed or dated as required, and a resident self-administered a breathing treatment without an assessment to determine their capability to do so. These lapses in care and documentation contributed to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. One resident, admitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and malignant neoplasm of the upper lobe, had no documentation related to COPD in their care plan. This oversight was acknowledged by the MDS Coordinator, who confirmed that COPD should have been included in the care plan. Another resident, with diagnoses of acute respiratory failure with hypoxia, acute pulmonary edema, congestive heart failure, asthma, COPD, dependence on supplemental oxygen, and obstructive sleep apnea, had a care plan that did not document the use of oxygen. Despite a physician's order and an assessment indicating the need for continuous oxygen, the care plan failed to reflect this requirement. The MDS Coordinator reviewed the care plan and confirmed that the use of oxygen should have been documented.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly labeling and dating food items. During a kitchen tour, surveyors observed ten plastic cups covered with clear wrap containing various colored liquids, including yellow, red, pink, white, and dark brown. None of these cups were labeled or dated, which is against the facility's policy as confirmed by a staff member. The Director of Nursing (DON) identified that 68 residents resided in the facility at the time of the observation.
Facility Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure the safety and cleanliness of its environment, as evidenced by two main observations. Firstly, the shower room on hall six was found to be in poor condition, with plastic draping taped to the walls and a grey, black, and white fuzzy substance observed on the ceiling and door jamb, indicating a lack of cleanliness and potential mold presence. Secondly, the janitor closet on the Southwest resident hall was found unlocked, containing hazardous materials such as multiple gallons of paint, a spray bottle of Windex cleaner, and a bottle labeled bleach without a lid, along with other unlabeled liquids, posing a risk to residents. The administrator acknowledged awareness of the unlocked janitor closet and stated that the housekeeping staff were responsible for cleaning the showers. However, there was no documented schedule for cleaning the shower rooms, only verbal instructions, indicating a lack of formalized procedures to ensure cleanliness and safety.
Failure to Honor Resident's Choice in Wake-Up Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing them to choose their preferred time to wake up. A resident, who was admitted with a diagnosis of depression, reported that they were routinely woken up by staff at 4:00 a.m., despite their preference to wake up naturally around 7:00 a.m. The resident expressed confusion and dissatisfaction with being woken up early only to sit until breakfast. An interview with the social services director confirmed that residents were not asked about their preferred wake-up times, indicating a lack of consideration for resident choices in daily routines.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of gait belts during resident transfers, as observed with one resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. The facility's policy required the use of a gait belt by two persons when moving a resident who cannot stand alone from bed to chair. However, during an observation, a CNA was seen transferring the resident from a recliner to a wheelchair without using the gait belt, instead lifting the resident by holding them under their arms. The CNA acknowledged the policy requirement to use gait belts during such transfers. The Director of Nursing confirmed that the gait belt should have been used in this instance.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects in residents receiving psychotropic medications, specifically for one resident out of five sampled. This resident had diagnoses including depression and was prescribed Sertraline, an antidepressant, and Risperidone, an antipsychotic, to be administered daily and at bedtime, respectively. However, a review of the resident's chart revealed a lack of documentation for side effect monitoring related to these medications. During an interview, the Director of Nursing (DON) acknowledged that side effect monitoring should have been conducted for the psychotropic medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holdenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boyce Manor Nursing Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Elmwood Manor Nursing Home | 6.5 mi | ★★★★★ | 6 | 2 |
| Wewoka Healthcare Center | 6.9 mi | — | 29 | 8 |
| Seminole Care And Rehabilitation Center | 18.6 mi | ★★★★★ | 0 | 0 |
| Seminole Pioneer Nursing Home | 18.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Heartway At Heritage Village Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.