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 Villa Care & Rehab Center during CMS and state inspections, most recent first.
The facility did not provide required written notices of transfer to residents or their representatives before transferring three residents to an acute care hospital. Transfers occurred for reasons including aggressive behavior, decreased oxygen saturation, and physical discomfort, but in each instance, the DON confirmed that no written notification was given.
A resident's right to dignity and privacy was not maintained when a CNA and two nurse aide students entered the resident's room while the resident was on the toilet, without informing the resident that additional people would be entering. The resident became upset and requested privacy, and the incident led to ongoing distress for the resident.
A facility failed to thoroughly investigate and document an injury of unknown origin after a resident was found with a forehead bruise. Although some staff and hospice employees were interviewed, not all relevant staff, such as an LPN who had recently assessed the resident, were included in the investigation, and interviews were not properly documented. The cause and timing of the injury were not determined, and the facility's own policy for investigating potential abuse or neglect was not fully followed.
A resident was found with a bruise on the forehead, which was identified by a family member and reported to staff. The LPN on duty did not perform a head-to-toe assessment or document the injury, and there were no progress notes or skin assessments recorded for that day. The DON confirmed that the LPN did not follow required procedures for assessment and documentation.
A resident did not receive medications as ordered by a nurse practitioner when the DON instructed the ADON to delay implementing changes to psychotropic medications during the DON's absence. As a result, the resident continued to receive a higher dose of Seroquel and did not receive newly prescribed Trazodone for several days.
A resident with hemiplegia and hemiparesis, requiring a two-person lift, was improperly transferred by a single CNA, resulting in a fall and an ankle fracture. The facility's policy required two staff members for such transfers, which was not followed, leading to the incident.
A facility failed to transmit a discharge MDS assessment within the required time frame for a resident. The resident was discharged without anticipation of return, but the MDS was transmitted late due to an incorrect selection on the electronic form. The error was discovered through a regional report, despite monthly checks by the MDS coordinator.
A resident with diabetes mellitus was not administered the correct dosage of insulin as per physician orders. The resident's blood sugar level was 213 mg/dL, which required three units of insulin according to the sliding scale. However, an LPN administered only two units. The LPN later admitted the mistake, and the DON confirmed the necessity of following physician orders.
A resident with muscle wasting and atrophy was found to have bed rails attached without documented consent or education on their use. The resident, who was cognitively intact, did not recall being informed about the risks or benefits of the bed rails. The facility lacked a specific policy on bed rail use, relying on CMS guidelines, and the DON acknowledged the absence of necessary documentation.
The facility failed to conduct involuntary movement assessments for a resident receiving antipsychotic medication, despite a care plan intervention to monitor for symptoms like EPS, TD, and pseudoparkinsonism. The resident, diagnosed with major depressive disorder and a history of falls, routinely received aripiprazole. The DON confirmed the lack of assessments for residents on antipsychotic medications.
Failure to Provide Written Notice of Transfer Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notice of transfer to residents and their representatives prior to transferring them to an acute care hospital. This deficiency was identified through record review and staff interviews, which revealed that for three sampled residents who were transferred to a hospital, neither the residents nor their representatives received the required written notification. The Director of Nursing (DON) confirmed that the facility did not issue written notices of transfer for these cases and was unaware of the requirement to do so. Specific incidents included a resident transferred due to aggressive behavior, another with decreased blood oxygen saturation and level of consciousness, and a third experiencing unusual physical discomfort and difficulty standing. In each case, progress notes documented the transfer to an acute care hospital, but there was no evidence of written notice being provided. The DON described the process for transferring residents and the forms sent with them but did not include a written letter of transfer as part of the process.
Failure to Ensure Resident Dignity and Privacy During Bathroom Use
Penalty
Summary
Staff failed to honor a resident's right to dignity and privacy when a certified nurse aide (CNA) and two nurse aide students entered a resident's room while the resident was using the bathroom. Although the CNA knocked and greeted the resident, they did not inform the resident that two students would also be entering. The resident was on the toilet with the bathroom door open and became visibly upset when they saw the group enter, expressing anger and requesting that the students leave. The resident continued to express distress about the incident for the remainder of the day and threatened to contact the state regarding the event. Facility policy required staff to knock and identify themselves before entering a resident's room, and the CNA had acknowledged and completed training on this policy. Despite this, the CNA admitted to not providing adequate privacy or treating the resident with dignity during the incident. The Director of Nursing (DON) confirmed that the CNA and students entered without properly informing the resident, which was inconsistent with facility training and expectations regarding resident rights.
Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation following the discovery of an injury of unknown origin for one resident. Review of the resident's progress notes for the specified period showed no documentation of a bruise, and a skin assessment performed by an LPN did not note any injury to the resident's forehead. However, an undated incident report indicated that the resident was found with a bruise of unknown origin on the forehead, and this was reported to the Oklahoma State Department of Health. The facility's policy requires an investigation to determine the cause and effect of any potential abuse or neglect, but this was not fully carried out. Interviews revealed that the administrator did not document interviews with all staff who worked with the resident, and some staff, including the LPN who performed the skin assessment, were not interviewed at all regarding the injury. The administrator acknowledged that documentation of the investigation was lacking, and both the administrator and DON confirmed that the cause and timing of the injury were not determined. The DON also admitted that a thorough investigation was not conducted and that more staff interviews should have been documented.
Failure to Complete and Document Full Assessment After Injury of Unknown Origin
Penalty
Summary
A resident was found to have a bruise on the forehead, which was first identified by a family member and brought to the attention of facility staff. The facility administrator became aware of the injury after it was pointed out by the family. Upon review, there were no progress notes or documentation in the resident's medical record regarding the bruise on the day it was discovered. Additionally, there were no skin assessments recorded for that day. The LPN on duty at the time confirmed being present when the bruise was found but did not recall the specifics of the incident. The LPN stated that they did not assess the rest of the resident's body for additional injuries and were unaware that a full assessment and documentation were required when a new injury was discovered. The DON later confirmed that the LPN had not followed their training, as a complete assessment should have been performed to ensure there were no other injuries.
Failure to Administer Medications as Prescribed by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a resident received medications as prescribed by a nurse practitioner, resulting in the administration of unnecessary drugs. Specifically, a nurse practitioner ordered a reduction in the resident's Seroquel dosage from 50mg to 25mg at bedtime and the initiation of Trazodone 50mg at bedtime. However, the Medication Administration Record (MAR) showed that the resident continued to receive Seroquel 50mg at bedtime for three days following the new order, and Trazodone was not added to the MAR, resulting in missed doses. The resident was prescribed these medications for dementia and related symptoms. The Director of Nursing (DON) acknowledged being aware of the new orders but instructed the Assistant Director of Nursing (ADON) to hold off on implementing any psychotropic medication changes while the DON was off duty. The ADON confirmed that they followed the DON's instructions and placed the orders in a folder for the DON to address upon return. As a result, the medication changes were not implemented before the resident was discharged from the facility. The DON later stated that it was probably not in the best interest of the resident to delay the implementation of these orders.
Inadequate Transfer Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) did not attempt to transfer a resident from a bed to a wheelchair by themselves, despite the resident requiring a two-person lift. This deficiency was identified for one of three sampled residents reviewed for falls. The resident in question had diagnoses including hemiplegia and hemiparesis, and their care plan interventions documented the need for assistance from two staff members during transfers. Additionally, a quarterly MDS assessment confirmed the resident's dependency on staff for transfers, and a later care plan intervention specified the requirement of a mechanical lift for all transfers. An incident occurred when CNA #1 attempted to transfer the resident without assistance, resulting in the resident's legs giving out and them being lowered to the floor. Subsequent medical evaluation revealed the resident complained of left ankle pain, and an x-ray confirmed an ankle fracture. Interviews with RN #1 and the Director of Nursing (DON) confirmed that the CNA did not follow the facility's policy on transferring residents, which required two-person assistance for this particular resident.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within the required time frame for one of the sampled residents. The facility's policy, dated 04/25/19, mandates that the MDS, a standardized comprehensive assessment, must be completed and electronically transmitted to CMS in compliance with federal guidelines. Resident #76 was admitted to the facility and later discharged on 09/20/24, with no anticipation of return. However, the discharge MDS was not transmitted on time. The MDS coordinator acknowledged that the discharge MDS for Resident #76 was transmitted late, on 01/11/25, due to an incorrect selection on the electronic form that prevented the document from being sent to CMS. The error was discovered when a regional employee's report indicated the discharge record had not been submitted, despite the coordinator running monthly reports, including in December 2024, without noticing the error.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to ensure physician orders were followed for insulin administration for a resident with diabetes mellitus and major depressive disorder. A physician order dated 04/10/23 specified that the resident was to receive insulin aspart according to a sliding scale: one unit for blood sugar between 150 and 175, two units for blood sugar between 176 and 200, and three units for blood sugar between 201 and 225. On 01/13/25, an LPN was observed performing a finger stick blood sugar test on the resident, which showed a level of 213 milligrams per deciliter. Despite this, the LPN administered only two units of insulin instead of the prescribed three units. The LPN later acknowledged the error, and the DON confirmed that physician orders should be followed.
Failure to Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was provided with education on the use of bed rails and given the option to consent or decline their use before they were attached to the bed. This deficiency was identified for one of four sampled residents reviewed for accident hazards. The resident, who had diagnoses including muscle wasting and atrophy, was observed with grab bar type rails attached to each side of their bed. Despite being cognitively intact, the resident stated they did not recall any discussion about the pros or cons of using the rails or giving consent for their use. The Director of Nursing (DON) acknowledged the lack of documentation showing that the resident had been educated on the dangers associated with bed rails and had given consent for their use. Additionally, the regional nurse confirmed that the facility did not have a specific policy regarding the use of bed rails, relying instead on posted CMS guidelines for assistive devices. The DON identified that 16 residents had bed rails attached to their beds, indicating a broader issue within the facility regarding the implementation and documentation of bed rail use and consent procedures.
Failure to Conduct Involuntary Movement Assessments for Antipsychotic Medication
Penalty
Summary
The facility failed to complete involuntary movement assessments for a resident receiving antipsychotic medication, which is a necessary step to monitor for potential side effects such as extrapyramidal symptoms (EPS), tardive dyskinesia (TD), and pseudoparkinsonism. This deficiency was identified during a review of records and interviews, specifically for a resident diagnosed with major depressive disorder and a history of repeated falls. The resident had a care plan intervention initiated to assess for these symptoms, but the assessments were not conducted. The resident was documented to routinely receive an antipsychotic medication, aripiprazole, as per a physician's order. The Director of Nursing (DON) confirmed that involuntary movement assessments were not completed for residents receiving antipsychotic medications.
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Illustrative
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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.
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Nursing homes near Bartlesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bartlesville Health And Rehabilitation Community | 1.2 mi | ★★★★★ | 1 | 1 |
| Ignite Medical Resort Adams Parc | 1.2 mi | ★★★★★ | 0 | 0 |
| Medicalodges Dewey | 2.7 mi | ★★★★★ | 0 | 0 |
| Forrest Manor Nursing Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Nowata Nursing Center | 16 mi | ★★★★★ | 1 | 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.