Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage At Brandon Place Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to follow enhanced barrier precautions and hand hygiene for a resident with wounds and a wound vac. Two CNAs provided incontinent care without gowns, one CNA did not sanitize hands when moving from dirty to clean tasks, an LPN changed a wound vac dressing without a gown and did not clean hands after removing gloves, and an ADON used the same gloves to clean wounds and apply a clean dressing.
Failure to follow wound vac orders for a resident with an abdominal surgical wound and multiple diagnoses, including DM2 and a skin infection. The wound vac was observed turned off and the dressing was not dated, while an LPN stated it had been off since the start of the shift and did not know how long it had been off. The physician order required removal of the vac dressing and alternate wound care if the device was off for more than two hours, and the DON stated the LPN did not follow the order.
Failure to Maintain Pressure Ulcer Dressings: A resident with multiple stage 3 and stage 4 pressure ulcers, diabetes, obesity, and a skin infection did not receive ordered wound dressings. During incontinent care, a CNA removed packing from the wound bed and did not notify the nurse, and the next day wound care was observed with no dressing covering the gluteal fold ulcers despite physician orders to clean, pack, cover, and secure the wounds with tape.
Failure to Post Notice of Past State Survey Results: Surveyors observed that the facility did not have a notice posted in a prominent, accessible area informing residents, representatives, and the public where past State survey results could be found. The survey results were located in a binder on the administrator's door in a file holder, and the DON identified 48 residents in the facility. The administrator stated there was no notice posted and that it should have been on the bulletin board.
Missed Scheduled Bathing for Dependent Residents: The facility failed to ensure bathing was provided as scheduled for multiple residents who needed ADL assistance. Documentation showed repeated missed showers for one resident with moderate cognitive impairment, one cognitively intact resident who was dependent for bathing, and one resident who was totally dependent on staff for showers. The DON confirmed the residents did not receive bathing at the frequency required by their schedules or care plans.
A resident with a fractured humerus and cognitive impairment experienced severe pain, but the facility failed to administer prescribed pain medication in a timely manner. Despite having orders for Oxycodone and morphine, the resident's pain was not managed according to policy, leading to an allegation of mistreatment.
The facility failed to protect residents from misappropriation of their bank cards and funds. A resident with heart disease reported unauthorized withdrawals totaling $900, while another with heart failure found unauthorized charges on their account, linked to staff. A third resident with cerebral infarction reported their debit card missing from the facility's safe. The facility's policy on preventing misappropriation was not effectively implemented.
A resident with severe cognitive impairment and medical conditions was found with a call light inaccessible, tucked under the foot of the bed, contrary to the facility's policy. A CNA confirmed the policy requires call lights to be within reach, but the resident could not have reached it due to its placement.
A resident with hypertensive heart disease reported unauthorized withdrawals from their bank account, totaling $900. The facility's investigation was incomplete, lacking identification of the suspended staff member and necessary documentation. The VP of Clinical Services admitted that the investigation did not include all required steps, such as safe surveys and staff in-services.
A facility failed to ensure lab tests were collected with a physician's order for a resident with chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. A lab report documented that a CBC, CMP, HbA1c, and prothrombin time with INR were collected without an order. The VP of clinical services confirmed the absence of a lab order and described the facility's process for handling lab services.
The facility breached resident confidentiality by releasing protected health information to unauthorized individuals. The previous administrator sent medical records to the corporate office for approval, which directed the release of a resident's records to their daughter. However, the records included information from other residents, violating the facility's policy on confidentiality.
A resident with dementia and a history of unsafe smoking caught on fire in their room due to inadequate supervision and access to smoking materials. Despite the facility's policy requiring supervision and secure storage of smoking supplies, the resident accessed a cigarette and lighter, resulting in severe burns. Previous incidents of the resident smoking unsupervised and non-compliance with smoking policies were documented, but effective interventions were not implemented.
The facility failed to develop comprehensive care plans for two residents, one with sepsis and heart conditions requiring hospice care, and another with a knee prosthesis infection and osteomyelitis. The first resident's care plan was not initiated beyond a 48-hour baseline, while the second resident's plan was incomplete, only addressing fall risk and antibiotic therapy.
A resident with severe cognitive and functional impairments was left in a wet state overnight, despite the facility's policy to check and change every two hours. Staff inconsistencies in following the policy were noted, with the resident last changed at 2:00 a.m. and found wet at 5:31 a.m.
A resident with multiple medical conditions and pressure ulcers experienced a decline in wound condition, including gangrene, due to the facility's failure to notify the physician of changes and schedule a vascular surgeon consult. Despite documentation of the resident's worsening condition, timely communication and follow-up were lacking, leading to a deficiency in care.
The facility did not adequately explain arbitration agreements to residents, leading to confusion and unawareness among them. Several residents, upon interview, stated they were unaware of signing such agreements and would not have done so if they understood the implications, such as giving up the right to sue. The administrator admitted difficulty in conveying the residents' right to refuse the agreement.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to follow enhanced barrier precautions and hand hygiene for Resident #1, who had wounds and a wound vac and was identified as requiring enhanced barrier precautions. During observed incontinent care, two CNAs provided care without wearing gowns even though a sign at the resident’s door stated staff must wear gowns and gloves for bathing, changing linen, and providing hygiene. One CNA also did not wash or sanitize hands when changing gloves and moving from a dirty area to a clean area. Later, an LPN changed the resident’s wound vac dressing without wearing a gown and stated they did not know the resident was on enhanced barrier precautions. After removing gloves, the LPN did not wash or sanitize hands. The next day, the ADON performed wound care, cleaned the pressure ulcer wounds to the gluteal folds, and used the same pair of gloves to apply a clean dressing. The DON stated the ADON should have changed gloves and washed hands between dirty and clean surfaces, and stated staff were to wear a gown and gloves per enhanced barrier precautions when providing contact resident care for the resident.
Failure to Follow Wound Vac Orders
Penalty
Summary
The facility failed to provide treatment and care according to physician orders for a resident with a wound vac to the abdomen. The resident had diagnoses including local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus, and a pressure ulcer of the back, buttock, and hip stage 2. On observation, the resident was lying in a bariatric bed with an air mattress and watching television, and the wound vac dressing on the abdomen was not dated while the wound vac machine was turned off. The treatment record showed orders for wound care to the midline abdomen surgical wound, including cleansing with full strength Dakins solution, applying barrier wipes, hydrocolloid, white vac foam, black foam, and setting negative pressure wound therapy twice weekly. A physician order also stated that if the wound vac was leaking, blocked, or off for more than two hours, the entire vac dressing was to be removed and an alternate dressing applied. An LPN stated the wound vac had been off since the start of the shift, did not know how long it had been off, and was unsure whether infection had built up under the dressing. The LPN later stated the wound vac should have been removed and the physician order followed after it had not worked for two hours. The DON stated the LPN should have followed the physician order and notified the physician about the wound vac not working correctly.
Failure to Maintain Pressure Ulcer Dressings
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to provide pressure ulcer treatments to promote healing and prevent infection for one resident with multiple pressure ulcers. The resident had diagnoses including local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus, obesity, depression, anxiety disorder, and pressure ulcer of contiguous site of back, buttock, and hip stage 2. An on-site wound visit report dated 04/29/26 documented a stage 4 pressure ulcer to the right gluteal fold measuring 6.6 cm by 12 cm by 3 cm, a stage 4 pressure ulcer to the left gluteal fold measuring 8 cm by 12.5 cm by 3.7 cm, and a stage 3 pressure ulcer to the right buttock measuring 2 cm by 2 cm by 0.1 cm. During incontinent care, two CNAs were observed providing care when one positioned the resident on their side and the other washed the buttock. Packing was present in the pressure ulcer, but there was no dressing covering the wound, and bowel was on the edges and inside edges of the pressure ulcer. While rolling soiled linen to discard it, the CNA caught the packing in the wound bed and removed part of the dressing with the linen, then did not tell the nurse that the packing had been removed. The next day, the ADON was observed completing wound care to the bilateral gluteal folds and there was still no dressing covering the pressure ulcer wounds. Physician orders dated 04/30/26 directed staff to clean the right and left gluteal fold wounds with Dakins quarter strength solution, apply soaked gauze, cover with a dressing, and secure with tape, and an LPN stated the orders should have been followed with tape to secure and cover the pressure ulcers.
Failure to Post Notice of Past State Survey Results
Penalty
Summary
The facility failed to post notice of the availability of past State survey results in areas that were prominent and accessible to residents, representatives, and the public. During a tour of the facility, surveyors observed that there was no notice informing the public where the past State survey results were posted. The past State survey results were later observed in a binder on the administrator's door in a file holder. The administrator stated that there was no notice posted about where to locate the past State survey results and said it should have been posted on the bulletin board. The DON identified that 48 residents resided in the facility.
Missed Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure residents were bathed as scheduled for 3 of 4 sampled residents reviewed for assistance with ADLs. The facility’s ADLs policy stated that bathing, dressing, and grooming services would be provided, and that residents unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The DON identified 38 residents who required assistance with bathing. Resident #7 had a bath schedule for showers three times weekly and was assessed as having moderate cognitive impairment with a BIMS of 12 and needing partial to moderate assistance with showers. Facility documentation showed multiple missed bathing opportunities in December 2025 and January 2026, and the resident stated they just did not get showers. Resident #3 had intact cognition with a BIMS of 14 and was dependent on staff for bathing; documentation showed repeated missed baths throughout November and December 2025, and the resident stated they had not had a shower in a month. Resident #1 was totally dependent on staff for showers two times per week and as necessary, but the documentation showed only two showers in December 2025, and the DON stated the resident did not receive two showers per week as required by the care plan.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who experienced severe pain. Resident #2, who was cognitively impaired and had a diagnosis of pain, dementia, and a fractured humerus, was admitted with a pain level of five on the PAINAD scale. Despite having physician orders for Oxycodone and morphine sulfate for pain management, the resident did not receive pain medication when their pain was assessed at a level of 10 on a numerical scale. There was no documented follow-up pain assessment as required by the facility's policy. The facility's narcotic count sheet indicated that morphine was available, yet it was not administered to the resident at the time of the initial high pain assessment. A subsequent pain assessment also recorded the resident's pain at a level of 10, and only then was morphine documented as given. The lack of timely pain management led to an allegation of abuse/mistreatment, which was reported and investigated. Interviews with staff revealed that the process for managing pain was not followed, as the resident was not offered pain medication despite a high pain rating.
Failure to Protect Residents' Financial Assets
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically their bank cards and funds. Three residents were affected by this deficiency. One resident, diagnosed with hypertensive heart disease with heart failure, reported unauthorized withdrawals from their bank account totaling $900. The resident had memory problems, and it was documented that they were advised not to give their bank card or cash to staff. Another resident, with combined systolic and diastolic heart failure and intact cognition, discovered unauthorized charges on their bank account. An investigation revealed that large amounts of money had been taken by current and previous employees over the past two years. A third resident, with cerebral infarction and moderate cognitive impairment, reported their debit card missing from the facility's safe. The staff member responsible for the card was terminated due to previous misappropriation incidents. The facility's policy on abuse, neglect, exploitation, and misappropriation of property was not effectively implemented, as evidenced by these incidents. The facility's failure to secure residents' financial assets and prevent unauthorized access by staff led to the misappropriation of funds.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach of a resident, which is a violation of their policy on call light accessibility and timely response. The policy mandates that all staff be educated on the proper use of the resident call system and that each resident's unique needs and preferences be evaluated to ensure access to the call light. During an observation, it was noted that the call light for a resident with severe cognitive impairment and diagnoses including weakness and congestive heart failure was tucked under the foot of the bed, making it inaccessible. A Certified Nursing Assistant (CNA) confirmed that the policy requires call lights to be close to residents at all times and acknowledged that the resident was able to use the call light. However, the call light was found clipped to the bottom of the blanket at the foot of the bed, which the CNA admitted the resident could not have reached. The CNA attempted to explain the situation by stating that someone had put the blanket on upside down, but could not provide a verbal response when asked how the resident would reach the call light in that position.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of misappropriation of resident property involving a resident diagnosed with hypertensive heart disease with heart failure. The resident reported that their bank card had been compromised, resulting in two unauthorized withdrawals totaling $900. An initial state reportable incident form was completed, documenting the allegation and indicating further information would follow. However, the final report did not identify the staff member who was suspended, nor did it include supplemental documentation regarding the investigation. The VP of Clinical Services acknowledged that they could not determine all the steps taken during the investigation or identify the suspended staff member. They also stated that the investigation should have included safe surveys and staff in-services, indicating that these steps were not completed. The resident's discharge assessment noted memory problems, which may have impacted their ability to manage their financial affairs independently. The lack of a thorough investigation and documentation highlights a deficiency in the facility's response to the alleged misappropriation.
Lab Tests Conducted Without Physician Order
Penalty
Summary
The facility failed to ensure that laboratory tests were collected with a physician's order for one of the three sampled residents reviewed for lab services. The facility's policy, revised in September 2012, required that a physician identify and order diagnostic and lab testing based on diagnostic and monitoring needs. However, a lab report dated October 13, 2024, documented that a CBC, CMP, HbA1c, and prothrombin time with INR were collected for a resident without a physician's order. The resident had diagnoses including chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. On December 5, 2024, the VP of clinical services confirmed that they could not locate a lab order for the tests collected on October 13, 2024, and described the facility's process for laboratory services, which includes receiving an order from the provider, contacting the lab, verifying completion, retrieving results, notifying the physician, and following up on new orders if indicated.
Breach of Resident Confidentiality in Record Release
Penalty
Summary
The facility failed to ensure the confidentiality of resident-identifiable records, resulting in the release of protected health information to unauthorized individuals. The deficiency occurred when the previous administrator followed a process where medical records requests were sent to the corporate office for approval. The corporate office directed the release of records for a resident to their daughter via email. However, the previous administrator did not review the records before sending them, leading to the inclusion of other residents' records mixed with the intended records. This action was against the facility's policy, which required staff to have appropriate in-service training on resident rights, including confidentiality of protected health information.
Failure to Supervise Resident with Unsafe Smoking History
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure to supervise a resident with a known history of unsafe smoking. The resident, who had dementia and required supervision while smoking, was admitted to the hospital with second and third-degree burns after catching on fire while smoking a lit cigarette in their room. The facility's policy required that residents who needed supervision with smoking have their smoking materials maintained by nursing staff, but this was not adhered to in the case of the resident. The resident's care plan documented that they required supervision while smoking and that their smoking supplies were to be stored on the nurse's cart. Despite this, the resident was able to access a cigarette and lighter, leading to the incident. Prior to the incident, there were multiple documented instances where the resident attempted to smoke unsupervised, refused to wear a smoking apron, and was non-compliant with the facility's smoking policy. Staff frequently reminded the resident about safety and requested assistance as needed, but these measures were insufficient to prevent the incident. Interviews with staff and other residents revealed that the resident had previously attempted to smoke inside the building and had been seen smoking unsupervised. Staff reported that the resident was non-compliant with care and smoking policies, and there were no effective interventions in place to prevent the resident from accessing smoking materials. The facility's failure to ensure the resident did not have access to smoking materials and was supervised during smoking led to the resident sustaining severe burns.
Removal Plan
- Social Services conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status.
- Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status.
- Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status.
- The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision.
- The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers.
- The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status.
- The Administrator attended the Resident Council to review the smoking policy with the residents.
- The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials.
- The DON and the Administrator conducted a smoking in-service for all employees. Ongoing education will be provided to new staff and as needed.
- The Administrator conducted QAPI to discuss the smoking policy and procedure.
- Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers.
- The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions.
- Admissions and Social Service will review the smoking times and policy with each new admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident #47, who was admitted with diagnoses including sepsis, atrial fibrillation, and congestive heart failure, was on hospice services and required significant assistance with daily activities. Despite a 48-hour baseline care plan being initiated, no comprehensive care plan was developed for this resident. Similarly, Resident #73, admitted with conditions such as infection due to a left knee prosthesis and acute osteomyelitis, required moderate assistance with daily activities. The care plan for this resident was incomplete, only addressing fall risk and antibiotic therapy, without a fully developed comprehensive care plan. These deficiencies were identified through observations, record reviews, and interviews with facility staff.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for all care. The resident, who was admitted with severe cognitive and functional impairments following a cerebral infarction, was observed to have been left in a wet state overnight. Despite the facility's policy to check and change residents every two hours, the resident was found wet at 5:31 a.m., with the last change documented at 2:00 a.m. Staff interviews revealed inconsistencies in following the policy, with CNAs stating that briefs were not to be used at night unless requested by the resident, and that checks were supposed to occur every couple of hours. The resident was unable to use the call light, further necessitating regular checks by the staff.
Failure to Notify Physician and Schedule Consult for Wound Care
Penalty
Summary
The facility failed to ensure proper notification of a change in condition for a resident with multiple wounds, including pressure ulcers. The resident, who had a medical history of atrial fibrillation, heart failure, hypertension, diabetes mellitus II, Alzheimer's disease, malnutrition, depression, COPD, CAD, and pressure ulcers, was readmitted to the facility with unstageable wounds on both heels, a non-pressure wound on the abdomen, and a Stage III pressure ulcer on the left buttock. Despite the presence of these wounds, there was a lack of timely communication and documentation regarding the changes in the resident's condition, as required by the facility's policy. The facility's staff, including LPNs and the DON, documented various observations and treatments for the resident's wounds over several months. However, there were significant lapses in communication and follow-up, particularly concerning the scheduling of a vascular surgeon consult. The resident's condition worsened, with the development of gangrenous wounds and a fracture in the left third toe, which were not promptly addressed. The wound physician noted the presence of gangrene and purulent drainage, indicating a severe deterioration in the resident's condition. The facility's failure to adhere to its policies for notifying physicians of significant changes in a resident's condition and ensuring timely consultations with specialists contributed to the deficiency. The lack of a scheduled vascular surgeon consult, despite recommendations, further exemplifies the facility's inadequate response to the resident's worsening condition. This deficiency highlights the need for improved communication and adherence to established protocols to ensure timely and appropriate care for residents with complex medical needs.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand. This deficiency was identified through record reviews and interviews, revealing that four sampled residents who entered into a binding arbitration agreement were not informed of their choice or right to refuse. During a resident council interview, nine residents, including the four sampled, expressed unawareness of what an arbitration agreement was or whether they had signed one. The ombudsman noted that digital documents often required signatures to proceed, potentially pressuring residents into signing. Two residents specifically stated they would not have signed the agreement had they known they were relinquishing their right to sue and questioned the rationale behind voluntarily giving up such rights. The administrator acknowledged the challenge in ensuring residents understood their right not to agree to arbitration.
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Illustrative
What surveyors actually found near you
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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 Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baptist Village Of Oklahoma City | 2.8 mi | ★★★★★ | 2 | 0 |
| The Lakes | 2.9 mi | ★★★★★ | 0 | 0 |
| St. Ann's Skilled Nursing And Therapy | 2.9 mi | ★★★★★ | 1 | 0 |
| The Health Center At Concordia | 3 mi | ★★★★★ | 0 | 0 |
| Epworth Villa Health Services | 4.6 mi | ★★★★★ | 0 | 0 |
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