Heritage Villa Care & Rehab: Medication Order Ignored - OK
The resident, identified in the inspection report only as Resident 1, had been prescribed Seroquel, an antipsychotic, for dementia. On March 20, a nurse practitioner ordered the dose cut in half, from 50mg to 25mg at bedtime, and added Trazadone, an antidepressant, at 50mg at bedtime as a new medication.
Neither change was made.
For three consecutive nights, March 20, March 21, and March 22, the resident received the original 50mg dose of Seroquel. The Trazadone was never added to the medication administration record at all. The resident missed three doses of a medication a licensed practitioner had determined they needed.
The explanation that emerged during the August inspection was direct and, by the end, the director of nursing acknowledged it herself.
When inspectors asked the DON on August 13 why the Seroquel reduction hadn't been implemented, she said she had been off work when the order came in. Before leaving, she told the assistant director of nursing to hold off on implementing any psychotropic medication orders while she was gone. She said she planned to handle those orders herself when she returned. When she did return, Resident 1 was gone.
The ADON confirmed the account. She told inspectors she had been instructed not to implement psychotropic medications while the DON was out. She put the orders in a folder and left them for her supervisor.
The next day, August 14, the DON told inspectors she felt it was "probably not in the best interest of the resident" to have held those orders until she got back.
The facility's own policy on physician orders states that orders from licensed practitioners, including nurse practitioners, are to be transcribed and implemented in accordance with professional standards. The nurse practitioner who wrote the orders on March 20 was authorized to prescribe. The orders were clear. The mechanism that was supposed to move a written order into a resident's care simply stopped because the person at the top of that chain decided to pause it.
Seroquel carries significant risks for elderly patients with dementia. The Food and Drug Administration has required a black box warning on antipsychotics used in that population since 2005, noting an increased risk of death. The nurse practitioner's decision to reduce the dose was a clinical judgment about that resident's care. The decision to wait was an administrative one.
Trazadone, the antidepressant that was never started, is commonly used in dementia care to address agitation, depression, and sleep disturbance. Whether Resident 1 experienced any of those symptoms during the three days the prescription sat unfilled, the inspection report does not say. The report classifies the harm level as minimal, or potential for actual harm.
The facility's director of nursing oversees medication administration for 77 residents, according to the DON's own statement to inspectors. The inspection was triggered by a complaint and reviewed three residents' medication records. One of the three had orders that were never implemented.
Resident 1 was discharged before anyone addressed the lapse. The folder, and whatever was in it, presumably stayed behind.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
HERITAGE VILLA CARE & REHAB CENTER in BARTLESVILLE, OK was cited for violations during a health inspection on August 14, 2025.
The resident, identified in the inspection report only as Resident 1, had been prescribed Seroquel, an antipsychotic, for dementia.
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.