Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Village Nursing Home during CMS and state inspections, most recent first.
A resident with cognitive impairment and physical care needs was forced by a CNA to use a bedpan instead of the requested bedside commode, resulting in a bruise and emotional distress. The incident was identified as neglect due to the failure to honor the resident's care preferences and provide necessary assistance.
A resident with respiratory issues did not receive adequate care, as the facility failed to document necessary assessments and follow-up after breathing treatments. Nursing staff did not conduct or document respiratory assessments despite the resident's deteriorating condition. Additionally, the facility did not adhere to policies for maintaining respiratory equipment for other residents, contributing to the deficiency.
The facility failed to develop comprehensive care plans for two residents, omitting critical medical needs such as COPD management and oxygen use. One resident's care plan lacked documentation for COPD, while another's did not include their continuous oxygen requirement, despite physician orders and assessments indicating its necessity.
The facility did not comply with food service safety standards by failing to label and date food items. During a kitchen inspection, surveyors found ten plastic cups with various colored liquids that were not labeled or dated, contrary to the facility's policy. The DON confirmed that 68 residents were in the facility at the time.
The facility was found deficient in maintaining a safe and clean environment. Observations revealed an unclean shower room with potential mold and an unlocked janitor closet containing hazardous chemicals. The administrator acknowledged the issues but lacked a documented cleaning schedule, relying on verbal instructions.
A resident with depression was routinely woken up at 4:00 a.m. by staff, despite preferring to wake up at 7:00 a.m. The social services director confirmed that residents were not asked about their preferred wake-up times, leading to a deficiency in honoring resident choice.
A facility failed to use a gait belt during the transfer of a resident with hemiplegia and hemiparesis, contrary to its policy. A CNA was observed lifting the resident from a recliner to a wheelchair without the gait belt, despite acknowledging the requirement to use it. The DON confirmed the gait belt should have been used.
A facility failed to monitor side effects for a resident receiving psychotropic medications, including Sertraline and Risperidone, prescribed for depression. The resident's chart lacked documentation of side effect monitoring, which was confirmed as necessary by the DON.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
A resident with a history of falls, muscle wasting, atrophy, and moderate cognitive impairment required assistance with personal care and was continent of bowel and bladder. During an incident, the resident was found to have a bruise on their right arm, which was noticed by family members. The resident reported that a CNA was persistent in requiring the use of a bedpan instead of the requested bedside commode, and expressed not wanting that CNA to provide care again. The resident was unaware of how the bruise occurred but stated they were afraid of the CNA involved. Facility records indicate that two CNAs were working on the resident's hall at the time of the incident. The investigation determined that one CNA had forced the resident to use the bedpan against their wishes, failing to provide care as requested by the resident. This action was identified as neglect, as it did not meet the resident's needs and preferences, and resulted in emotional distress and physical harm as evidenced by the bruise.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with new onset respiratory changes, leading to an Immediate Jeopardy situation. The resident, who had diagnoses including congestive heart failure and dementia, experienced shortness of breath and wheezing. Despite a physician ordering a breathing treatment, the facility did not document a comprehensive respiratory assessment, including lung sounds and post-treatment oxygen saturation. Vital signs were inconsistently recorded, and there was no documented follow-up assessment after treatments. The nursing staff did not conduct or document necessary respiratory assessments for the resident, despite being aware of the resident's deteriorating condition. The day shift RN acknowledged the resident's respiratory issues but failed to document a focused assessment. The evening shift RN also did not assess the resident, and the night shift RN discovered the resident had passed away without prior assessment. The Director of Nursing (DON) admitted there was no policy for respiratory assessment, relying instead on general nursing practices. Additionally, the facility did not adhere to its own policies regarding the maintenance of respiratory equipment for other residents. Oxygen tubing and humidifier bottles were not changed or dated as required, and a resident self-administered a breathing treatment without an assessment to determine their capability to do so. These lapses in care and documentation contributed to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. One resident, admitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and malignant neoplasm of the upper lobe, had no documentation related to COPD in their care plan. This oversight was acknowledged by the MDS Coordinator, who confirmed that COPD should have been included in the care plan. Another resident, with diagnoses of acute respiratory failure with hypoxia, acute pulmonary edema, congestive heart failure, asthma, COPD, dependence on supplemental oxygen, and obstructive sleep apnea, had a care plan that did not document the use of oxygen. Despite a physician's order and an assessment indicating the need for continuous oxygen, the care plan failed to reflect this requirement. The MDS Coordinator reviewed the care plan and confirmed that the use of oxygen should have been documented.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly labeling and dating food items. During a kitchen tour, surveyors observed ten plastic cups covered with clear wrap containing various colored liquids, including yellow, red, pink, white, and dark brown. None of these cups were labeled or dated, which is against the facility's policy as confirmed by a staff member. The Director of Nursing (DON) identified that 68 residents resided in the facility at the time of the observation.
Facility Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure the safety and cleanliness of its environment, as evidenced by two main observations. Firstly, the shower room on hall six was found to be in poor condition, with plastic draping taped to the walls and a grey, black, and white fuzzy substance observed on the ceiling and door jamb, indicating a lack of cleanliness and potential mold presence. Secondly, the janitor closet on the Southwest resident hall was found unlocked, containing hazardous materials such as multiple gallons of paint, a spray bottle of Windex cleaner, and a bottle labeled bleach without a lid, along with other unlabeled liquids, posing a risk to residents. The administrator acknowledged awareness of the unlocked janitor closet and stated that the housekeeping staff were responsible for cleaning the showers. However, there was no documented schedule for cleaning the shower rooms, only verbal instructions, indicating a lack of formalized procedures to ensure cleanliness and safety.
Failure to Honor Resident's Choice in Wake-Up Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing them to choose their preferred time to wake up. A resident, who was admitted with a diagnosis of depression, reported that they were routinely woken up by staff at 4:00 a.m., despite their preference to wake up naturally around 7:00 a.m. The resident expressed confusion and dissatisfaction with being woken up early only to sit until breakfast. An interview with the social services director confirmed that residents were not asked about their preferred wake-up times, indicating a lack of consideration for resident choices in daily routines.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of gait belts during resident transfers, as observed with one resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. The facility's policy required the use of a gait belt by two persons when moving a resident who cannot stand alone from bed to chair. However, during an observation, a CNA was seen transferring the resident from a recliner to a wheelchair without using the gait belt, instead lifting the resident by holding them under their arms. The CNA acknowledged the policy requirement to use gait belts during such transfers. The Director of Nursing confirmed that the gait belt should have been used in this instance.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects in residents receiving psychotropic medications, specifically for one resident out of five sampled. This resident had diagnoses including depression and was prescribed Sertraline, an antidepressant, and Risperidone, an antipsychotic, to be administered daily and at bedtime, respectively. However, a review of the resident's chart revealed a lack of documentation for side effect monitoring related to these medications. During an interview, the Director of Nursing (DON) acknowledged that side effect monitoring should have been conducted for the psychotropic medications.
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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 Holdenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boyce Manor Nursing Home | 1.7 mi | — | 0 | 0 |
| Elmwood Manor Nursing Home | 6.5 mi | — | 6 | 2 |
| Wewoka Healthcare Center | 6.9 mi | — | 12 | 6 |
| Seminole Care And Rehabilitation Center | 18.6 mi | — | 0 | 0 |
| Seminole Pioneer Nursing Home | 18.8 mi | — | 0 | 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 August 2026) and official state health department websites.