Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heavener Nursing & Rehab during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple diagnoses was not allowed to have private visits with their daughter due to restrictions imposed by their grandson, who did not have power of attorney. Staff followed the grandson's instructions to limit visits, despite the resident's wishes and facility policy guaranteeing 24-hour access to visitors of the resident's choice. The administrator was unaware of these restrictions.
Two residents admitted with complex medical conditions, including diabetes, bipolar disorder, Parkinson's disease, and malnutrition, did not have comprehensive admission assessments completed within the required fourteen-day period. The MDS coordinator confirmed that these assessments were overdue and had not been performed since admission.
Quarterly MDS assessments were not completed on time for five sampled residents, with the MDS coordinator confirming delays in assessment completion. Required quarterly assessments were missing for multiple individuals, despite the facility's obligation to update each resident's assessment at least every three months.
Several residents, including new admissions and those with specific care needs such as bed rail use and hospice services, did not have comprehensive care plans developed or updated as required. The MDS coordinator confirmed that care plans were not completed within the expected timeframe or did not address key interventions.
A resident returned from the hospital with an indwelling urinary catheter but did not have a physician order or documented diagnosis for its use. The resident was cognitively intact, always continent of bladder, and there was no documentation of catheter care. Facility staff, including the DON, were unaware of the catheter, and facility policy requiring timely removal in the absence of an order was not followed.
The facility did not ensure that monthly medication regimen reviews were completed and properly documented by a licensed pharmacist for several residents with complex medication needs. Multiple months of required reviews were missing from the medical records, and some available reviews lacked dates, contrary to facility policy.
Surveyors found that food items, including scrambled eggs, sausage links, meat, and vanilla pudding, were stored in the walk-in refrigerator without required labels or dates. The dietary manager confirmed that these items should have been labeled and dated, and that meals prepared in the kitchen were served to 65 residents.
Staff failed to follow Enhanced Barrier Precautions (EBPs) during high-contact care activities, such as wound care and PEG tube medication administration, by not using gowns in addition to gloves and not ensuring PPE and signage were available. Multiple staff members were unaware of EBP requirements, and the Infection Preventionist confirmed that EBPs were not being utilized or taught, resulting in noncompliance with infection control protocols for residents with wounds, indwelling devices, or feeding tubes.
A resident with dementia, anxiety, and depressive disorders was admitted to hospice care, but the facility did not complete the required significant change assessment at the time of hospice admission. The MDS coordinator confirmed this assessment should have been done.
Failure to Ensure Resident Visitation Rights
Penalty
Summary
The facility failed to ensure that a resident was allowed to have visitors of their choice, as required by visitation rights. The resident, who had diagnoses including depression and hypertension and was assessed as moderately cognitively impaired, reported that their grandson was preventing their daughter from visiting them in their room. The resident expressed a desire for private visits with their daughter and stated that they had informed the social services director about the issue, but no action was taken. The grandson, who did not have power of attorney, instructed staff to only allow visits in the lobby or outside and requested that a witness be present during visits due to ongoing arguments between the daughter and grandson. Staff, including the housekeeping supervisor and an LPN, confirmed that the grandson did not have legal authority over the resident and that the resident was their own responsible party. Despite this, staff followed the grandson's instructions regarding visitation restrictions. The administrator was unaware that the resident's visitation rights were being restricted by the grandson. The facility's policy stated that residents should have 24-hour access to visitors of their choice with the resident's consent, but this policy was not followed in this case.
Failure to Complete Timely Comprehensive Admission Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments within fourteen days for two residents who were recently admitted. One resident was admitted with diagnoses including type II diabetes mellitus and bipolar disorder, while the other had Parkinson's disease and protein-calorie malnutrition. Record review showed that neither resident had a comprehensive admission assessment documented in their clinical records. During an interview, the MDS coordinator confirmed that comprehensive admission assessments for both residents had not been completed since their admission and acknowledged that these assessments should have been done within the required timeframe.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed for five out of thirteen sampled residents. Specifically, for each of these residents, the required quarterly assessment was not completed within three months of their last assessment, as evidenced by missing assessment reference dates for the expected quarters. The MDS coordinator confirmed during an interview that they were behind on completing many residents' assessments and acknowledged that the quarterly assessments should have been completed within the required timeframe. The facility had a total of 65 residents at the time of the review.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, as required. Two newly admitted residents with significant medical conditions, including type II diabetes mellitus, bipolar disorder, Parkinson's disease, and protein-calorie malnutrition, did not have comprehensive care plans documented in their clinical records. The MDS coordinator confirmed that these care plans had not been completed within the required 21-day timeframe following admission. Additionally, two residents who were observed using bed rails did not have this intervention addressed in their care plans, despite their diagnoses of cerebral infarction, diabetes mellitus, unspecified dementia, metabolic encephalopathy, and chronic kidney disease. The MDS coordinator acknowledged that bed rail use should have been included in the care plans. Furthermore, a resident admitted to hospice care did not have hospice services reflected in their care plan, even though there was a physician's order for hospice admission. The MDS coordinator confirmed that the care plan should have been updated to include hospice services.
Lack of Physician Order and Assessment for Indwelling Urinary Catheter
Penalty
Summary
A resident who returned from the hospital with an indwelling urinary catheter did not have a current physician order or documented diagnosis supporting the use of the catheter. The resident, who had a history of urinary tract infection and diabetes mellitus, was assessed as cognitively intact and always continent of bladder. Upon review, the treatment and medication administration records did not show any documentation of catheter care for this resident. Interviews with facility staff, including an LPN and the DON, confirmed that there was no physician order or diagnosis for the catheter, and the DON was unaware that the resident had an indwelling urinary catheter. Facility policy required removal of a catheter within 24 hours if no order was present, but this was not followed. The deficiency was identified for one resident, with the DON noting that there were 11 residents in the facility with indwelling urinary catheters.
Failure to Complete and Maintain Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRRs) for all residents receiving medications, as required by facility policy. For five sampled residents with complex medication regimens, including antipsychotics, antidepressants, antianxiety, anticoagulants, hypoglycemics, and opioids, the facility was unable to provide complete monthly MRR documentation for the period from January 2024 through February 2025. The policy required that MRRs be completed upon admission and at least monthly thereafter, with copies maintained in the permanent medical record. Record review and interviews revealed that for each of the five residents, multiple months of required MRRs were missing, and in several instances, the available reviews lacked dates indicating when pharmacy recommendations were made. The corporate regional director of operations confirmed the inability to locate all required MRRs for the affected residents and acknowledged that the reviews should have been completed monthly and kept in the medical record, as per policy.
Failure to Label and Date Food Items in Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in the walk-in refrigerator. During a kitchen inspection, a container with scrambled eggs and two sausage links, as well as a container of meat in six plastic bags (one of which was open to air), were found without labels or dates. Additionally, a large container identified as vanilla pudding was also not labeled or dated. The facility's policy, revised in October 2024, requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a 'use by' date. The dietary manager confirmed that these items should have been labeled and dated, and identified that 65 residents consumed meals prepared by the kitchen. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Implement Enhanced Barrier Precautions for Infection Control
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Enhanced Barrier Precautions (EBPs) as required by its own policy and CDC guidance. Observations revealed that staff did not use gowns in addition to gloves during high-contact care activities for residents with wounds, indwelling devices, or feeding tubes. Specifically, one LPN performed wound care for a resident with a coccyx wound using only gloves, without donning a gown or ensuring PPE and signage were available at the room entrance. The LPN was unaware of the need for additional precautions. Another LPN also performed wound care for a resident with a biliary drainage tube, again using only gloves and without proper signage or gown use, and expressed uncertainty about EBP requirements. Additionally, an ACMA administered medications through a PEG tube to a resident while wearing only gloves, with no gown or PPE available at the room. The ACMA stated they had not been educated on EBPs and were unaware of the need for a gown during such procedures. The Infection Preventionist confirmed that EBPs were not being utilized in the facility, staff had not been educated on their use, and appropriate signage and PPE were not in place for residents with wounds, catheters, PEG tubes, or other indwelling devices. The facility's failure to implement and educate staff on EBPs resulted in noncompliance with infection control protocols for multiple residents.
Failure to Complete Significant Change Assessment Upon Hospice Admission
Penalty
Summary
The facility failed to complete a significant change resident assessment when a resident was admitted to hospice services. Record review showed that the resident, who had diagnoses of unspecified dementia, anxiety, and depressive disorders, was admitted to hospice per a physician's order. However, there was no documentation that a significant change assessment was performed at the time hospice services began. The MDS coordinator confirmed that a significant change assessment should have been completed for this resident.
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 3 citations issued within 25 miles in the last 12 months — 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 Heavener
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks Healthcare Center | 10.4 mi | ★★★★★ | 3 | 0 |
| Spiro Nursing Home, Inc. | 23.7 mi | ★★★★★ | 0 | 0 |
| Talihina Manor | 26.2 mi | ★★★★★ | 0 | 0 |
| Pocola Health And Rehab | 26.4 mi | ★★★★★ | 1 | 0 |
| The Springs Of Waldron | 28.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Heavener Nursing & 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.