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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Hills Living & Rehabilitation Center during CMS and state inspections, most recent first.
Protected health information, including clinical records and personal identifiers, was found unsecured in an unlocked room containing multiple file cabinets and loose documents. The DON confirmed that these records were not stored according to facility policy, which requires locked storage with restricted access.
A resident with incontinence was directed by an LPN to return inside for cleaning after soiling themselves but refused, leading to the LPN grabbing the resident's chair and causing them to slide to the ground. Witnesses reported that the LPN then poured water over the resident and made derogatory remarks, including showing photos of the incident to others. Multiple staff and residents described the LPN's actions as abusive and humiliating, resulting in the resident sustaining minor injuries and emotional distress.
Surveyors found that hazardous chemicals, including floor polish and sanitizer, were stored in an unsecured resident room that could not be locked. The chemicals were accessible to residents and not secured as required by facility policy, with the DON confirming that only housekeeping and maintenance should have access.
A computer displaying protected health information (PHI) was repeatedly left open and unattended on a medication cart in the East/West Hall, making confidential resident information visible and accessible. The administrator and DON confirmed that the computer should not have been left open in this manner.
Surveyors observed a significant fly infestation in common areas and a resident room, including flies in and around cups of liquid and on resident furnishings. The facility did not ensure a clean and comfortable environment for its 54 residents, as required.
Two residents with histories of substance use and mental health conditions were repeatedly found smoking illegal substances using soda cans, but their care plans did not address this behavior. Staff confirmed that care plans were not developed to manage or mitigate the ongoing substance use.
Two residents with histories of substance abuse and mental health diagnoses were repeatedly found using illegal substances within the facility. Staff responded by confiscating the substances and providing education, but no substance abuse program or additional services were offered, and the administrator was unfamiliar with the facility's policy regarding such incidents.
A CNA used unnecessary force while assisting a resident with hemiparesis and hearing impairment in a wheelchair, admitting to acting out of frustration. This action violated facility policy prohibiting abuse and was documented in an incident report.
The facility failed to maintain a clean, safe, and homelike environment, with observations of broken tiles, scuffed walls, and mold in bathrooms. Staff and family representatives noted the disrepair, and the DON acknowledged the facility's policy was not followed. The administrator admitted to lacking a specific policy and recognized the need for repairs, despite not viewing the condition as severely inadequate.
The facility failed to protect two residents from abuse, with one resident exhibiting a history of aggression that was not documented or addressed in their care plan. This resident pushed another, resulting in a head injury. Staff interviews revealed a lack of communication and documentation regarding supervision and interventions to prevent further abuse.
The facility did not have a water management program to prevent Legionella growth. The maintenance supervisor was unaware of the requirement, and the IP confirmed the absence of policies and procedures for managing waterborne pathogens.
The facility was found deficient in maintaining the kitchen's physical environment and ensuring proper hygiene practices. Observations revealed a broken paper towel dispenser, missing door trim, a broken light fixture cover, sticky substance buildup on walls, and rusted air vents. Additionally, a male employee with a partial beard was seen not wearing a beard guard on two occasions.
The facility failed to ensure accurate resident assessments for two residents, with incorrect documentation of a psychotic disorder diagnosis. Despite having other diagnoses, their assessments inaccurately recorded a psychotic disorder. The IP confirmed no residents had this diagnosis, and the MDS coordinator attributed the error to previous assessments.
The facility failed to change and label oxygen tubing weekly as per physician orders for four residents receiving respiratory treatments. Observations showed that the tubing was not changed on the specified date, and the Director of Nursing confirmed the oversight.
The facility failed to notify the OHCA of new serious mental disorder diagnoses for two residents, as required by the PASARR program. One resident was diagnosed with a persistent mood disorder, and another with delusional disorder, but there was no documentation of OHCA contact for either case.
The facility failed to enforce its smoking policy and ensure proper storage of oxygen tanks. A resident was observed vaping in their room, contrary to the policy allowing smoking only in designated areas, and quarterly smoking assessments were not completed. Another resident had an unsecured oxygen tank in their room, which should have been stored in the nurse's closet.
The facility failed to investigate an abuse incident where a resident with major depressive disorder pushed another resident with Alzheimer's, causing injury. Despite the incident's severity, there was no documentation of a thorough investigation. Staff interviews revealed inconsistencies in supervision and interventions for the aggressive resident, and the DON admitted to not completing the necessary reports. The administrator acknowledged the lack of documentation, indicating a deficiency in handling abuse allegations.
Unsecured Storage of Resident Health Information
Penalty
Summary
The facility failed to securely store protected health information for its residents. During an observation, an unsecured resident room at the end of the East hall was found to contain three 4-drawer and one 5-drawer tall file cabinets, all unlocked, with loose papers and files on top. These documents included residents' names, birthdates, social security numbers, insurance information, laboratory results, and physician's progress notes. Two of the file cabinets contained additional resident clinical records. The Director of Nursing (DON) confirmed the unsecured state of the storage room and records, and acknowledged that facility policy requires all resident records to be kept behind locked doors with keys stored in the administrator's office.
Failure to Maintain Abuse-Free Environment for Resident
Penalty
Summary
A resident with a history of incontinence and requiring supervised smoking was involved in an incident where they defecated in the hallway and proceeded outside to smoke, despite being directed by staff to return indoors for cleaning. Multiple staff and resident statements indicate that an LPN confronted the resident outside, and after the resident refused to return inside immediately, the LPN grabbed the resident's chair, resulting in the resident sliding to the ground. Witnesses reported that the LPN then went inside, returned with a pitcher of water, and poured it over the resident, who was still on the ground. Several staff and residents described the resident as being soaked with water in areas inconsistent with incontinence, and the resident reported feeling humiliated by the LPN's actions and comments, which included making fun of the resident and showing photos of the incident to others. The LPN's own account differed, stating that the water was used to clean feces from the concrete and the resident's feet, and that the chair was grabbed to prevent the resident from falling backward. However, multiple witness statements contradicted this, describing the LPN's actions as punitive and disrespectful, including pouring water over the resident and making derogatory remarks comparing the resident to a pet. Staff also reported that the LPN showed photos of the resident's feces to other residents and laughed about the incident, further contributing to the resident's distress and humiliation. The resident involved sustained scrapes on their elbow, hip, and knee as a result of the incident and expressed emotional distress, stating they had never been treated in such a manner before. Other residents and staff who witnessed the event described the LPN's behavior as uncalled for and abusive. The incident was reported to facility administration, and statements were collected from all involved parties, documenting the sequence of events and the actions taken by the LPN that led to the deficiency in maintaining an abuse-free environment.
Unsecured Hazardous Chemicals Found in Resident-Accessible Storage Room
Penalty
Summary
Surveyors observed that the facility failed to secure hazardous chemicals in a resident-accessible area. Specifically, an unsecured resident room at the end of the East hall was being used for storage and contained six 1-gallon bottles of chemicals, including ZEP Wet Look Floor Polish, Floor Front Floor Finish, and Betco Advanced Alcohol Gel Sanitizer. The storage room door could not be locked, and the chemicals were not secured, despite each bottle having warning labels to keep out of reach of children. The DON confirmed the chemicals were accessible and acknowledged that staff were aware of the requirement to keep such items locked and only accessible to housekeeping and maintenance. Review of the facility's policy indicated that all chemicals must be secured with locks and only accessible to authorized personnel. The MSDS for the chemicals present in the room detailed potential harms, including skin and eye irritation, respiratory irritation, and flammability. At the time of the observation, there were no wandering residents seen on the East hall, but the unsecured chemicals presented a potential hazard. The DON observed the unsecured chemicals and reiterated the facility's policy regarding chemical security.
Unattended Computer Displaying PHI on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' protected health information (PHI) as required. On multiple occasions, a computer displaying PHI was observed left open and unattended on top of a medication cart in the East/West Hall. These observations occurred at various times over two consecutive days, with the computer screen visible and accessible while staff were not present. The administrator confirmed that the computer should have been closed and not displaying PHI when unattended. The facility had 54 residents at the time of the observations.
Failure to Maintain a Fly-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents by not ensuring the environment was free from flies. On observation, flies too numerous to count were present in the lobby, including in and around cups of liquid next to a resident resting in a recliner, with a dead fly observed floating in one of the cups. Further observation in a resident room revealed flies all over the room, bed, and bedside table. The presence of flies was directly observed by surveyors, and the facility had not yet implemented effective measures to address the infestation at the time of the survey. The administrator confirmed that 54 residents resided in the facility during the time of the deficiency. No specific medical history or conditions of the residents involved were mentioned in the report.
Failure to Address Illegal Substance Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans addressing the use of illegal substances for two residents with histories of substance use and mental health diagnoses. One resident with schizoaffective disorder, opioid dependence, and psychotic disorder was found smoking an illegal substance using a soda can, as documented in a nurse note, but their care plan did not address this behavior. Another resident with major depressive disorder, hypoxemia, and alcoholic hepatitis was also found smoking an illegal substance from a soda can, with no corresponding care plan intervention. Both residents had been caught multiple times engaging in this behavior, and staff interviews confirmed that care plans were not developed to address the issue.
Failure to Provide Substance Abuse Services and Supervision
Penalty
Summary
The facility failed to provide appropriate services for residents with substance abuse issues, as evidenced by two residents repeatedly found using illegal substances on the premises. Facility records and nurse notes documented multiple incidents where these residents were found smoking illegal substances, often using improvised devices such as soda cans. In each instance, staff provided education about the risks of recreational drug use and reminded residents of the facility's policy prohibiting such substances. Despite these interventions, the residents continued to use illegal substances, and the facility's response was limited to confiscating the substances and re-educating the residents. The facility's policy stated that marijuana was not allowed due to federal funding, and outlined steps for staff to take when residents were found with marijuana, including notifying authorities and conducting an investigation. However, the administrator acknowledged that no substance abuse program or additional services were offered to residents with substance abuse diagnoses. The administrator also indicated a lack of familiarity with the facility's policy, and confirmed that the facility's approach was limited to confiscation of substances when discovered.
Unnecessary Force Used by CNA During Resident Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used unnecessary force while assisting a resident in a wheelchair in the facility lobby. The resident had a medical history of left-sided hemiparesis/hemiplegia and bilateral hearing impairment. According to an incident report, the CNA admitted to acting out of frustration, stating the resident was 'getting on my last nerve.' This action was observed and documented, and it was found to be in violation of the facility's policy prohibiting mistreatment, neglect, or abuse of residents. The incident was reported to the Oklahoma State Department of Health, and the facility's records confirmed the occurrence of the event.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its 59 residents, as observed during two separate inspections. Observations included broken and cracked tiles in the main hallway and resident rooms, creating trip hazards, and sharp edges on the double doors leading from the front commons. The walls in the main center hallway and commons area were scuffed and damaged, and the tiled floors on the East hall were chipped, stained, and damaged. Additionally, there was brown stained residue on the tiles, and the baseboards and corners were damaged. The halls had missing paint, damaged sheetrock, and resident doors were scuffed with marks. There were also cracked tiles and black mold around the toilet and shower area on the North hall. Interviews with staff and family representatives revealed a consensus that the facility was in disrepair. Housekeeping staff noted that the tiles needed replacement and that the walls were scuffed from residents' wheelchairs. A family representative commented that the facility could use some help, and CNAs described the floors as stained and cracked, with walls soiled from spilled drinks and scuffed from carts and wheelchairs. The Director of Nursing (DON) acknowledged the disrepair, noting concerns about the fire doors, damaged corners, and baseboards, and stated that the facility's policy for maintaining a clean, safe, and sanitary environment was not being followed. The facility administrator admitted that the maintenance staff had quit and that the facility lacked a specific policy regarding maintaining a clean, safe, and homelike environment, relying instead on resident rights. The administrator acknowledged the need for repairs, including redoing the floors, replacing corners, and fixing the fire doors. Despite these acknowledgments, the administrator did not believe the facility's condition was severely inadequate, citing the challenges of caring for the residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents, one with major depressive disorder and another with Alzheimer's disease. The first resident exhibited a history of verbal and physical aggression, including incidents of yelling, cursing, and physically threatening staff and peers. Despite these behaviors, there was no documentation of interventions or care plans addressing these aggressive tendencies. The second resident, who was severely cognitively impaired, was pushed by the first resident, resulting in a head injury and hospitalization. The incident was witnessed by another resident, who confirmed that the aggression was unprovoked. The facility's documentation lacked evidence of an investigation into the incident, and there was no record of any preventive measures being implemented to address the aggressive behavior of the first resident. Interviews with staff revealed a lack of communication and documentation regarding the supervision and care of the first resident. Staff members were not instructed to provide one-on-one supervision, and there was no clear documentation of any interventions to prevent further abuse. The Director of Nursing and other staff members acknowledged the absence of a documented care plan for the resident's aggressive behaviors, highlighting a significant oversight in the facility's management of resident safety.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. During a record review and interview, it was found that there was no documentation of water management policies and procedures. The maintenance supervisor was unaware of the requirement for a water management program, stating that the facility did not need one because they never had any standing water. Additionally, the Infection Preventionist (IP) confirmed that the facility did not have policies and procedures to reduce the risk of growth and spread of Legionella.
Kitchen Hygiene and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the physical environment of the kitchen and ensure proper hygiene practices among kitchen staff. During observations, several issues were noted: a broken paper towel dispenser at the handwashing sink, missing trim on the exterior door, a broken cover on a fluorescent light fixture, a buildup of a brown sticky substance on the walls around the grill area, and rusted air vents on the ceiling. Additionally, a male employee with a partial beard was observed on two separate occasions not wearing a beard guard while in the kitchen. These deficiencies were identified during a survey involving 58 residents residing in the facility.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents out of a sample of 15. One resident had diagnoses including depression, anxiety, mood disorder, and intermittent explosive disorder, but their annual assessment inaccurately documented a diagnosis of psychotic disorder. Another resident with an impulse disorder also had a quarterly assessment inaccurately documenting a psychotic disorder. The Infection Preventionist (IP) confirmed that no resident in the facility had a diagnosis of psychotic disorder and was unsure why the assessments contained this error. The MDS coordinator, who started their position in December, reported that they documented the psychotic disorder diagnosis based on previous assessments, leading to the inaccuracies.
Failure to Change and Label Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the changing and labeling of oxygen tubing for four residents receiving respiratory treatments. The facility's policy required oxygen tubing to be changed weekly and labeled with the date and initials. However, observations revealed that the oxygen tubing for all four residents was not changed as per the physician's orders. The tubing for each resident was labeled with a date that was not consistent with the weekly change requirement, indicating that the tubing had not been changed on the specified date. Resident #17, diagnosed with COPD and chronic respiratory failure with hypercapnia, was observed with oxygen tubing labeled with a date that was not in compliance with the weekly change order. Similarly, Resident #28, also diagnosed with COPD and chronic respiratory failure, had tubing labeled with an outdated date. Resident #31, who had shortness of breath, and Resident #50, with multiple respiratory and cardiac conditions, were both found with tubing labeled with the same outdated date. The Director of Nursing acknowledged that the tubing had not been changed according to the physician's orders.
Failure to Notify OHCA of New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of new possible serious mental disorder diagnoses for two residents, which is a requirement for the Pre-Admission Screening and Resident Review (PASARR) program. Resident #37, who initially had no serious mental illness documented in a Level I PASARR dated 07/19/21, was diagnosed with a specified persistent mood disorder on 10/06/21. However, there was no documentation indicating that the OHCA had been contacted to determine if a Level II PASARR was necessary. Similarly, Resident #20, who had diagnoses including diabetes mellitus and adjustment disorder with depressed mood, was diagnosed with delusional disorder on 01/06/23. The facility did not document any contact with the OHCA regarding this new diagnosis, as confirmed by the administrator's statement and the absence of documentation in the resident's medical record.
Failure to Enforce Smoking Policy and Secure Oxygen Tanks
Penalty
Summary
The facility failed to ensure compliance with its smoking policy and proper storage of oxygen tanks, leading to potential safety hazards. A resident with a diagnosis of nicotine dependence was observed vaping inside their room, contrary to the facility's policy that restricts smoking and vaping to designated areas. The resident's care plan indicated they were an unsupervised smoker and were expected to adhere to the facility's smoking policy. However, the resident believed it was permissible to vape in their room if their roommate did not object. Additionally, the facility did not complete quarterly smoking assessments for this resident, as required by their policy. Another resident, who had diagnoses of COPD and respiratory failure, was found with an unsecured oxygen tank standing upright in their room. The facility's policy requires oxygen tanks to be locked in the nurse's closet, but this was not adhered to, posing a potential safety risk. The Director of Nursing acknowledged that the oxygen tanks should not have been left unsecured in the resident's room.
Failure to Investigate Resident Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of abuse involving two residents. Resident #33, who had diagnoses including major depressive disorder and suicidal ideations, was reported to have physically assaulted Resident #59, who had Alzheimer's disease and was severely cognitively impaired. The incident occurred when Resident #33 pushed Resident #59, resulting in a fall and head injury for Resident #59. Despite the severity of the incident, there was no documentation of a comprehensive investigation into the abuse. Interviews with staff revealed inconsistencies and a lack of clarity regarding the supervision and interventions implemented for Resident #33 following the incident. CNA #1 and CNA #2 both stated they were not instructed to provide one-on-one supervision of Resident #33, contradicting the DON's statement that such supervision was in place. Additionally, LPN #1 confirmed that no interventions were implemented to prevent further abuse, despite Resident #33's history of verbal and physical aggression. The DON admitted to not completing the incident report or investigation, and the IP nurse and ADON, who were responsible for these tasks, could not locate any documentation of the investigation. The administrator acknowledged the absence of documentation and stated that an investigation should have been conducted. This lack of documentation and follow-through on the investigation process highlights a significant deficiency in the facility's handling of abuse allegations.
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 8 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 Mcalester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mitchell Care & Rehab Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Mcalester Nursing & Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| New Hope Retirement & Care Center | 2 mi | ★★★★★ | 8 | 0 |
| Walnut Grove Care & Rehab Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Beare Manor | 15 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.