Heritage at Brandon Place Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Heritage at Brandon Place Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 20, 2024

  On 08/16/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2, who had a known history of unsafe smoking did not smoke in their room and catch themselves on fire. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #2 was admitted to the hospital on 08/11/24 with second and third degree burns. On 08/16/24 at 11:45 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to for Res #2 smoking in their room and catching themselves on fire. […]

• Actual harm, isolatedF697Dec 9, 2024

  Based on record review and interview, the facility failed to ensure a resident who experienced pain received treatment for pain for one (#2) of three sampled residents reviewed for pain management. The VP of clinical services identified 46 residents had orders for pain management in the facility. Findings: The Administering Pain Medications policy, revised 10/10, read in part, The pain management program is based on a facility-wide commitment to resident comfort. The policy also read, .Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained .Administer pain medication as ordered .document the following in the resident's medical record: results of the pain assessment; medication; dose; route of administration; and… […]

• No harm, potential for more than minimal, widespreadF577Jan 14, 2026

  Based on observation and interview, the facility failed to post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to residents, representatives, and the public.The DON identified 48 residents resided in the facility. Findings:On 01/12/26 at 11:34 a.m., a tour of the facility was conducted. There was no notice informing the public where the past State survey results were posted.On 01/12/26 at 11:40 a.m., the past State survey results were observed in a binder on the administrator's door in a file holder.On 01/12/26 at 11:44 a.m., the administrator stated the there was no notice posted about where to locate the past State survey results. They stated it should have been posted on the bulletin board.

• No harm, potential for more than minimal, patternF725Aug 10, 2026

  Based on observation and interview, the facility failed to provide sufficient medication aide staffing to ensure residents' medication needs were being met.The regional director of operations identified 52 residents resided in the facility.Findings:On 08/06/26 at 10:44 a.m., CMA #1 was observed completing the morning medication pass. CMA #1 was observed to be one hour late filling the medication they were doing at the time.On 08/06/26 at 3:19 p.m., CMA #1 was observed still completing medication pass.On 08/05/26 at 8:55 p.m., Resident #3 stated they were not getting some of their medications and they had told the CNAs, but the CNAs had not been able to do anything because there was no CMA available.On 08/05/26 at 11:07 p.m., Resident #10 stated they received their medications late and that… […]

• No harm, potential for more than minimal, patternF755Aug 10, 2026

  Based on observation, record review, and interview, the facility failed to:a. remove medications of discharged residents from refrigerator #2 for 2 (#13 and #18) of 15 sampled residents reviewed for medication storage; and b. return and/or destroy unused medications in the medication storage room. The regional director of operations identified 52 residents resided in the facility and three refrigerators in the medication storage room.Findings:1. On [DATE] at 8:08 p.m., refrigerator #2 was observed to have Latonoprost 0.005% eye drops for Resident #13, who had expired [DATE].On [DATE] at 8:29 p.m., refrigerator #2 was observed to have Novolog 100 unit/ml flexpen for Resident #18, who had expired [DATE].An undated policy titled Medication Storage, read in part, Outdated, contaminated,… […]