Heritage Villa: Nurse Failed to Assess Injured Resident - OK
The nurse also failed to document any assessment of the nickel-sized bruise that appeared several days old, according to federal inspection records from Heritage Villa Care & Rehab Center.
The facility's administrator first learned about the resident's forehead bruise on April 12 when a family member showed it to them. But no progress notes exist in the resident's medical record documenting the injury or any assessment that day, the director of nursing told inspectors on August 14.
LPN #1 was on duty when the family member pointed out the bruise. When inspectors asked the nurse to describe what they saw and did, the nurse said they couldn't recall exactly but confirmed a family member had discovered the injury.
The nurse described the bruise as about nickel-sized and appearing several days old. But when inspectors asked if they had found any other injuries that day, LPN #1 admitted they hadn't assessed the rest of the resident's body.
"They stated that at that time they were not aware they should have assessed the rest of the body when they discovered a new injury," according to the inspection report.
The nurse also acknowledged they hadn't documented their observations of the resident that day because they were unaware they should document their assessment.
Federal regulations require nursing homes to provide appropriate treatment and care according to medical orders and residents' needs. When staff discover injuries of unknown origin, protocols typically call for comprehensive head-to-toe assessments to identify any additional harm.
The facility's director of nursing confirmed that LPN #1 had not followed their training. The DON told inspectors the nurse should have assessed the resident to ensure there were no other injuries.
Heritage Villa's administrator documented the incident in an addendum to a final incident report dated May 15 — more than a month after becoming aware of the bruise. The administrator identified this as the facility's only resident found to have an injury of unknown origin between March 1 and August 13.
The case raises questions about staff training and oversight at the 120-bed facility on Woodland Loop Drive. Federal inspectors noted the failure represented a breakdown in basic nursing assessment protocols when unexplained injuries are discovered.
Injuries of unknown origin in nursing homes trigger specific documentation and investigation requirements designed to protect vulnerable residents. The failure to conduct a complete physical assessment could have left other potential injuries undetected.
The inspection found the facility failed to ensure proper assessment procedures for one of three residents reviewed for injuries of unknown origin during the complaint investigation.
LPN #1's admission that they were unaware of basic injury assessment protocols suggests potential gaps in staff education about fundamental nursing responsibilities. The nurse's acknowledgment that they didn't know documentation was required for injury assessments points to broader training deficiencies.
The director of nursing's statement that the LPN had not followed their training indicates the facility had policies in place but failed to ensure staff compliance. The month-long delay between the administrator's awareness of the incident and formal documentation also raises questions about the facility's incident reporting procedures.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The finding occurred during a complaint investigation completed August 14, suggesting external concerns prompted the regulatory review.
Heritage Villa must submit a plan of correction addressing how it will prevent similar failures in resident assessment and documentation. The facility faces potential enforcement actions if it fails to demonstrate adequate remedial measures.
The case illustrates how basic nursing care breakdowns can compromise resident safety in long-term care settings. When staff lack awareness of fundamental assessment protocols, vulnerable residents may not receive the comprehensive evaluations needed to identify and address injuries promptly.
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
- View all inspection reports for Heritage Villa Care & Rehab Center
- Browse all OK nursing home inspections
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 13, 2026 · Our methodology
HERITAGE VILLA CARE & REHAB CENTER in BARTLESVILLE, OK was cited for violations during a health inspection on August 14, 2025.
The facility's administrator first learned about the resident's forehead bruise on April 12 when a family member showed it to them.
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.
Frequently Asked Questions
- What happened at HERITAGE VILLA CARE & REHAB CENTER?
- The facility's administrator first learned about the resident's forehead bruise on April 12 when a family member showed it to them.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BARTLESVILLE, OK, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from HERITAGE VILLA CARE & REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 375109.
- Has this facility had violations before?
- To check HERITAGE VILLA CARE & REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.