Heritage Villa Care & Rehab: Bruise Investigation Failures - OK
That detail sits at the center of a complaint inspection completed August 14 at Heritage Villa Care & Rehab Center, a nursing home at 1244 Woodland Loop Drive in Bartlesville. Federal inspectors found that after a memory care resident on hospice — identified in records only as Resident 3 — was discovered with an unexplained bruise on their forehead in April, the facility conducted an investigation so incomplete that the one nurse who had performed a head-to-toe skin assessment of the resident the day before the bruise appeared was never contacted at all.
Four months later, no one at Heritage Villa could say how the injury happened, or when.
The bruise was discovered on April 12. A skin assessment completed the previous day, April 11, by a licensed practical nurse identified as LPN 2, showed no injury to the resident's forehead. That gap, roughly 24 hours in which something happened to a hospice patient living in a memory care unit, was the window the investigation was supposed to explain. It never did.
An incident report, undated, documented the bruise and classified the injury as unknown origin. A time stamp showed the Oklahoma State Department of Health received that report on April 12, the same day the bruise was found. The facility had, at minimum, put the state on notice. What it did not do was build any record of what its own staff knew.
When inspectors sat down with the administrator on August 13, the administrator offered an explanation for the investigation's limits. Resident 3 lived in the memory care unit, they said, so interviewing the resident directly wasn't possible. They had obtained written statements from two hospice employees who had worked with Resident 3, and from LPN 1, the facility nurse on duty when the bruise was found. Beyond that, the administrator acknowledged speaking with some staff members but said none of those conversations had been written down. "They stated they should have documented their investigation," inspectors noted in the report.
The administrator also acknowledged the most basic failure: four months of inquiry had produced no answer. They had not discovered what occurred or when.
The director of nursing said the same thing the following morning. They had not conducted a thorough investigation, the DON told inspectors, and should have interviewed and documented more interviews with facility staff.
What neither the administrator nor the DON mentioned was LPN 2, the nurse whose skin assessment on April 11 was the last documented evidence that Resident 3's forehead was uninjured before the bruise appeared. That nurse, interviewed by inspectors on August 14, said she had worked with Resident 3 around the time the bruise was found. She confirmed performing the head-to-toe assessment on April 11 and seeing no injury to the forehead at that time. Then inspectors asked whether anyone had spoken to her about the bruise after it was discovered.
No one had talked to her about it. Not the administrator. Not the director of nursing. Not anyone.
LPN 2 was, by the logic of any reasonable investigation, the most important witness the facility had. She had eyes on Resident 3 the day before the injury appeared. She could have described the resident's condition, who else was present, what the unit looked like, whether anything seemed unusual. Instead, she went the next four months without being asked a single question.
The facility's own policy on abuse, neglect, and exploitation, dated April 29, stated that an investigation would be initiated at the time of any finding of potential abuse or neglect to determine cause and effect and to protect alleged victims during the investigation's continuation. That policy was dated more than two weeks after the bruise was found. Whether it reflected a revision triggered by the incident or was simply a scheduled update, the report does not say. What the report makes clear is that whatever investigation the facility conducted before or after that policy was written, it did not include the nurse who had last examined Resident 3.
The resident's progress notes from April 1 through April 30 contained no documentation of a bruise being found at all. The incident report itself carried no date. The only timestamp connecting the injury to a specific moment was the state's receipt of the report on April 12.
For a resident living in a memory care unit on hospice, the circumstances that produced an unexplained forehead bruise carry particular weight. Memory care residents cannot describe what happened to them. They cannot say whether they fell, whether someone was rough with them, whether they struck something in the night. The investigation that exists in their place is the facility's responsibility. At Heritage Villa, that responsibility produced written statements from three people, undocumented conversations with an unspecified number of others, and no interview at all with the nurse whose assessment bracketed the injury.
Inspectors classified the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. The finding covered one of three residents reviewed for injuries of unknown origin during the complaint inspection.
The administrator did not dispute the failure. The director of nursing did not dispute it either. Both said, in essentially the same words, that more should have been done. The administrator said they should have documented their investigation. The DON said they should have interviewed and documented more interviews with staff.
What neither explanation addressed was what happens now to the question of how Resident 3's forehead was bruised. The investigation that was supposed to answer that question is four months old. The staff members who worked in that unit in April have had four months of distance from whatever they saw or didn't see. LPN 2, whose memory of April 11 was the sharpest evidentiary thread the facility had, was never pulled.
The bruise has healed. The cause remains unknown. The resident, who was on hospice when the injury was found, was living in a unit designed for people who cannot speak for themselves. Heritage Villa's investigation, such as it was, did not speak for them either.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HERITAGE VILLA CARE & REHAB CENTER in BARTLESVILLE, OK was cited for violations during a health inspection on August 14, 2025.
Four months later, no one at Heritage Villa could say how the injury happened, or when.
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.