Heritage Villa: Failed Transfer Notices for 64 Patients - OK
Federal inspectors found the facility violated transfer notification requirements for every sampled case they reviewed. Three residents were rushed to hospitals for medical emergencies without their families receiving the legally mandated written notices explaining their rights.
The violations came to light during a complaint inspection completed August 14. When asked about the transfer process, Director of Nursing acknowledged the facility "had not been giving those statements."
One case involved a resident who became aggressive on March 27. The administrator was called to the facility at 10:55 a.m. after the assistant director of nursing reported the behavioral incident. The resident was transferred to an acute care hospital the same day.
No written notice was provided.
Another resident was found July 25 with dangerously low blood oxygen levels and decreased consciousness. Medical staff documented the emergency at 11:24 a.m. and transferred the patient to a hospital immediately.
Again, no written notice.
A third resident reported unusual physical discomfort on August 5 and was found unable to stand properly. The 6:01 p.m. progress note showed this patient was also transferred to acute care without the required documentation.
When inspectors pressed the director of nursing about specific cases, she confirmed none of the residents or their representatives had received written transfer notices. The facility's own policy, dated November 2018, states that transfer forms should be completed and sent with residents moved to other healthcare facilities.
But the policy appears to address only the medical paperwork, not the notification rights guaranteed to residents and families under federal law.
During the inspection, the director of nursing described the standard transfer process and the medical forms that accompany patients to hospitals. She made no mention of written notices to families.
The oversight affects dozens of families. Between February 14 and August 14, Heritage Villa transferred 64 residents to hospitals for various medical emergencies and conditions requiring acute care.
Federal regulations require nursing homes to provide written notices before transfers, explaining the reasons for the move and informing residents of their appeal rights. These protections exist because nursing home transfers can be traumatic and sometimes inappropriate.
The written notice requirement serves multiple purposes beyond simple notification. It creates a paper trail for families who might question the necessity or timing of a transfer. It also ensures residents understand their legal options if they believe the transfer is unwarranted.
For facilities, the requirement provides legal protection by documenting that proper procedures were followed. The notices must include specific information about bed-hold policies, which determine whether residents can return to the same room after hospitalization.
Heritage Villa's administrator was directly involved in at least one transfer decision. Progress notes show the administrator came to the facility after being contacted about the aggressive resident's behavior and participated in the decision to transfer.
Yet even with administrative oversight, the facility failed to provide the required documentation.
The director of nursing's admission that she was "unaware they were required to give a written notice of transfer" suggests the violation was systematic rather than isolated to specific cases. Her statement indicates the facility had never implemented proper transfer notification procedures.
This knowledge gap is particularly concerning given the volume of transfers. Sixty-four hospital transfers in six months represents more than two transfers per week from the Bartlesville facility.
The inspection focused on transfer notifications after receiving a complaint about the facility's practices. Inspectors reviewed medical records and interviewed staff to understand the facility's procedures.
When confronted with the evidence, facility leadership could not dispute the findings. The director of nursing acknowledged the facility had not been providing written notices to any residents or their representatives before hospital transfers.
The violation carries minimal harm classification, meaning inspectors determined no residents suffered immediate injury from the missing notices. However, the "potential for actual harm" designation recognizes that families were denied important legal protections.
Heritage Villa operates at 1244 Woodland Loop Drive in Bartlesville. The facility must now implement proper notification procedures and train staff on federal transfer requirements.
The 64 families whose relatives were transferred to hospitals between February and August never received the written notices explaining their rights or the reasons for their loved ones' emergency moves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Villa Care & Rehab Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HERITAGE VILLA CARE & REHAB CENTER in BARTLESVILLE, OK was cited for violations during a health inspection on August 14, 2025.
Federal inspectors found the facility violated transfer notification requirements for every sampled case they reviewed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.