Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
23 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 29, 2025, following a self-reported incident received on July 21, 2025, regarding allegations in Resident Care and Related Services and Safe, Secure Environment.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Renewal
Census: 23
Deficiencies: 2
Date: Apr 28, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with regulations including failure to ensure annual review of resident rights documentation and failure to properly implement the medication management plan, including unsecured medication cart and loose pills found during audit.
Deficiencies (2)
Failure to ensure that the rights and responsibilities of residents were reviewed annually and documented in resident records.
Failure to implement portions of the medication management plan, including leaving the medication cart unlocked and presence of loose pills in the medication cart.
Report Facts
Number of residents present: 23
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the inspection |
| Holly Copeland | Licensing Inspector | Contact person for questions about the inspection findings |
Inspection Report
Monitoring
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
The inspection was a monitoring visit conducted on November 20, 2024, following a self-reported incident received on November 11, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 6/26/2024 regarding allegations in the areas of Admission, Discharge, and Retention of residents, and Resident Care and Related Services.
Complaint Details
Complaint related inspection triggered by allegations concerning Admission, Discharge, and Retention of residents, and Resident Care and Related Services. The complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Report Facts
Number of residents present: 22
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 24
Deficiencies: 1
Date: May 21, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards related to health care oversight documentation for residents meeting assisted living level of care criteria. A violation notice was issued and a plan of correction was requested.
Deficiencies (1)
Facility failed to complete a health care oversight for residents who meet criteria for assisted living level of care at least every six months as required.
Report Facts
Number of residents present: 24
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Inspector conducting the inspection |
Inspection Report
Monitoring
Census: 21
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 2 and April 4, 2024, following a self-reported incident received by VDSS regarding allegations related to additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, with no substantiated deficiencies found.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Interviews conducted with staff: 1
Interviews conducted with residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to correctly implement the scheduled/controlled medication monitoring system, specifically concerning narcotic medication accounting for Resident #19.
Complaint Details
The complaint investigation revealed that on 07/20/23, LPN #1 documented removing two tablets of Oxycodone but only administered one, resulting in a discrepancy in controlled drug counts. LPN #1 admitted to dropping a medication and wasting it without a witness and accidentally administering the medication twice. The discrepancy was identified by LPN #4 on 07/22/23 but was not immediately reported. The agency nurse involved was investigated but no follow-up was reported. Resident #19 did not report pain or complaints during interviews.
Findings
The facility failed to ensure accurate accounting of scheduled/controlled medications, specifically Oxycodone for Resident #19. Discrepancies were found in medication administration records and controlled drug records, including documentation errors and unreported medication disposal by nursing staff.
Deficiencies (1)
Failure to ensure nursing staff correctly implemented the facility's scheduled/controlled medication monitoring system to accurately account for scheduled/controlled medications for Resident #19.
Report Facts
Tablets of Oxycodone delivered: 16
Medication administration date: 2023
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented medication administration errors and admitted to dropping and wasting medication without a witness. |
| LPN #3 | Licensed Practical Nurse | Signed for receiving medication and counted narcotics with LPN #1 but did not physically check medications. |
| LPN #4 | Licensed Practical Nurse | Identified the medication count discrepancy on 07/22/23. |
| LPN #5 | Unit Manager | Notified of the medication discrepancy on 07/24/23. |
| LPN #6 | Licensed Practical Nurse | Signed as receiving nurse for medication delivery and counted narcotics with LPN #4. |
| Administrator | Provided information about medication charges and participated in interviews and video review. | |
| Director of Nursing | Participated in video review of medication administration. |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, pharmaceutical services, and food safety at Brandon Oaks Nursing and Rehabilitation Center.
Findings
The facility failed to accurately code a significant change MDS assessment to capture hospice status for one resident, failed to ensure accurate accounting of scheduled/controlled medications for another resident, and failed to dispose of out-of-date food items in the kitchen.
Deficiencies (3)
Failed to accurately code a significant change MDS assessment to capture hospice status for Resident #31.
Failed to ensure nursing staff correctly implemented the scheduled/controlled medication monitoring system to accurately account for scheduled/controlled medications for Resident #19.
Failed to dispose of out-of-date carnation sweetened condensed milk in the main kitchen.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: Many
Medication tablets delivered: 16
Medication tablets delivered: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and narcotic accounting deficiency |
| LPN #3 | Licensed Practical Nurse | Involved in narcotic count and interview regarding medication discrepancy |
| LPN #4 | Licensed Practical Nurse | Identified narcotic count discrepancy |
| LPN #5 | Unit Manager | Notified about narcotic medication discrepancy |
| LPN #6 | Licensed Practical Nurse | Counted narcotics and reported discrepancy |
| Registered Nurse #1 | Registered Nurse | Acknowledged missing hospice documentation on MDS |
Inspection Report
Renewal
Deficiencies: 11
Date: May 22, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for Brandon Oaks Intensive Assisted Living.
Findings
The inspection found multiple violations related to resident assessments, staff training, documentation, and medication management. The facility failed to ensure proper assessments for residents with serious cognitive impairments, obtain required approvals, provide staff training on duties and aggressive behavior, maintain required documentation, and implement medication management plans.
Deficiencies (11)
Failed to ensure residents were assessed as having serious cognitive impairment prior to admission to a safe, secure environment.
Failed to obtain written approval from required persons prior to placing a resident with serious cognitive impairment in a safe, secure environment.
Failed to ensure staff member in charge was informed of duties and responsibilities and provided written documentation.
Failed to maintain certain personal and social data in staff records, including verification of receipt of current job description.
Failed to ensure direct care staff were trained in methods of dealing with residents with aggressive behavior prior to involvement in care.
Failed to provide written assurance to a resident that the facility has the appropriate license to meet care needs at admission.
Failed to obtain all required personal and social information on a person prior to or at time of admission.
Failed to ensure a uniform assessment instrument (UAI) was completed as required, including missing administrator signature.
Failed to ensure individualized service plan (ISP) contained all required components, including listing private duty aides.
Failed to ensure annual review of resident rights and responsibilities was conducted and documented.
Failed to implement medication management plan requiring controlled drugs to be counted each shift by nursing staff.
Report Facts
Inspection duration hours: 6
Resident admission date: Apr 17, 2023
Resident admission date: Dec 23, 2022
Staff hire date: Jun 30, 2020
Staff hire date: Apr 5, 2023
Staff hire date: Feb 27, 2023
Resident admission date: Dec 9, 2021
Date of resident rights review: Apr 10, 2020
Date of resident rights review: Feb 2, 2021
Medication management plan effective date: Jun 1, 2022
Medication cart audit period: 21
Inspection Report
Monitoring
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
The inspection was a monitoring visit to review compliance with personnel and building standards at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Report Facts
Technical Assistance: 610
Inspection Report
Renewal
Deficiencies: 6
Date: Jun 14, 2022
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for Brandon Oaks Intensive Assisted Living.
Findings
The inspection identified multiple violations including unsecured harmful materials accessible to residents with serious cognitive impairments, incomplete staff orientation and training records, lack of first aid certification for a staff member, inaccuracies in individualized service plans, incomplete medication management plan, and unscreened operable windows.
Deficiencies (6)
Facility failed to ensure harmful materials were inaccessible to residents with serious cognitive impairment.
Staff did not receive required orientation and training within seven days of employment.
Direct care staff member lacked first aid certification within 60 days of employment.
Individualized service plans did not contain all required components and contained inaccuracies.
Medication management plan did not include methods to ensure accurate counts of controlled substances.
Operable windows in resident rooms were not effectively screened.
Report Facts
Staff hire date: Mar 30, 2022
Inspection time: 7
Dates of resident assessments: Nov 30, 2021
Date of medication management plan: Dec 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Current inspector conducting the inspection |
| Holly Copeland | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
A renewal inspection was initiated to review the facility's compliance with Assisted Living Facility regulations during renovations to become a secured memory care facility.
Findings
No violations with applicable standards or law were found during the remote documentation review portion of the inspection; no residents were present due to ongoing renovations.
Report Facts
Staff records reviewed: 3
Resident records reviewed: 0
Inspection Report
Routine
Deficiencies: 3
Date: Aug 24, 2021
Visit Reason
The inspection was conducted to evaluate compliance with physician orders for medication administration, medication storage and disposal, and food storage and safety standards at Brandon Oaks Nursing and Rehabilitation Center.
Findings
The facility failed to follow physician orders for medication administration for one resident, failed to dispose of expired injectable medications in one medication storage room, and failed to ensure food was stored under safe and sanitary conditions in a walk-in freezer and a drink/prep refrigerator.
Deficiencies (3)
Facility staff failed to ensure residents receive treatment by following physician orders concerning medication administration for Resident #9, specifically not measuring the ordered dosage of Diclofenac Sodium 1% gel.
Facility staff failed to dispose of expired injectable medications, including Influenza Vaccine prefilled syringes and Tuberculin Purified Protein solution, in the Appalachian Unit medication storage room.
Facility staff failed to ensure food was stored under safe and sanitary conditions; frozen foods were not sealed in containers in the walk-in freezer and multiple milk containers in the RC kitchen's drink/prep refrigerator were expired.
Report Facts
Residents in survey sample: 29
Medication storage rooms: 3
Expired milk containers: 11
Medication dosage: 4
Medication dosage used: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered nurse observed failing to follow physician's orders for medication administration | |
| LPN #1 | Licensed practical nurse who accompanied surveyor during medication room observation and verified expired medications | |
| Administrator | Attended meetings discussing deficiencies | |
| Director of Nursing | Attended meetings discussing deficiencies | |
| Appalachian Unit Manager | Attended meeting discussing medication administration deficiency | |
| Blue Ridge Unit Manager | Attended meeting discussing medication administration deficiency | |
| Food Service Manager | Accompanied surveyor during kitchen and food storage observations | |
| Kitchen Supervisor | Discussed expired milk containers with food service manager | |
| Unit Manager | Received expired medications from LPN #1 |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 27, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, accurate assessments, care planning, and food safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including incomplete advanced directives for residents, failure to notify physicians of late medication administration, inaccurate MDS discharge coding, incomplete care plans, failure to administer medication per physician orders, and improper food storage practices in resident accessible refrigerators.
Deficiencies (6)
Failure to ensure the resident's right to formulate an advanced directive by failing to ensure the advanced directive in the resident's record was complete for 2 of 19 residents.
Failure to notify the physician regarding administration of routine scheduled medications at times other than scheduled for 1 of 19 residents.
Failure to ensure an accurate MDS (minimum data set) for 1 of 19 residents due to incorrect discharge coding.
Failure to have an interdisciplinary team prepared, resident-centered comprehensive care plan specifying transfer handling for 1 of 19 residents.
Failure to administer medication per physician's order for 1 of 19 residents.
Failure to properly store food in resident accessible refrigerators including undated food and expired milk in 2 of 2 Nourishment Stations.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
BIMS score: 12
BIMS score: 8
BIMS score: 7
Medication dose: 12.5
Pulse parameter: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Participated in administrative team meetings regarding deficiencies | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and care plan deficiencies |
| Administrator | Administrator | Participated in administrative team meetings regarding deficiencies |
| Administrator in Training | Participated in administrative team meetings regarding deficiencies | |
| RN #1 | Registered Nurse | Provided modified discharge MDS for Resident #53 |
| LPN #1 | Licensed Practical Nurse | Discussed MDS discharge coding for Resident #53 |
| Unit Manager #2 | Clarified medication order parameters for Resident #217 | |
| CDM | Certified Dietary Manager | Interviewed and observed food storage issues in nourishment stations |
Viewing
Loading inspection reports...
