4 Reports · 1 Summary
Inspection Summary
11 inspections covered, Sep 2021 – May 2026.
Inspection Reports Summary
Visit Reason
This report covers 11 inspections of Brandon Oaks Intensive Assisted Living from September 27, 2021 to May 6, 2026, including one complaint survey.
Complaint Details
One inspection was prompted by a complaint received on 06/26/2024 regarding allegations in Admission, Discharge, and Retention of residents and Resident Care and Related Services. The investigation did not support the allegations of non-compliance.
Findings
Across that history VDSS cited 20 violations under 16 distinct standards. Four visits ended with violations cited and seven with none.
Violations (20)
22VAC40-73-550-G: Failed to ensure annual review of resident rights with residents or representatives.
22VAC40-73-640-A: Failed to implement medication management plan; med cart left unlocked and loose pills found.
22VAC40-73-490-A-2: Failed to complete health care oversight every six months by licensed professional.
22VAC40-73-1100-A: Failed to obtain written approval prior to placing resident with serious cognitive impairment in safe, secure environment.
22VAC40-73-190-C: Failed to provide staff with training and written documentation of duties before placement in charge.
22VAC40-73-380-A: Failed to obtain all required personal and social information at admission.
22VAC40-73-250-C: Failed to maintain certain personal and social data in staff records.
22VAC40-73-310-D: Failed to provide written assurance of appropriate license to resident at admission.
22VAC40-73-1090-A: Failed to assess residents as having serious cognitive impairment prior to admission to safe, secure environment.
22VAC40-73-640-A: Failed to implement medication management plan; lacked documentation of controlled drug counts each shift.
22VAC40-73-270-1: Failed to ensure direct care staff trained in managing aggressive residents prior to care involvement.
22VAC40-73-550-G: Failed to ensure annual review of resident rights with residents or representatives.
22VAC40-73-440-D: Failed to complete uniform assessment instrument as required.
22VAC40-73-450-C: Failed to ensure individualized service plan contained all required components.
22VAC40-73-860-D: Failed to ensure operable windows were effectively screened.
22VAC40-73-450-C: Failed to ensure individualized service plan contained all required components.
22VAC40-73-260-A: Failed to ensure direct care staff obtained first aid certification within 60 days of employment.
22VAC40-73-120-A: Failed to ensure staff received required orientation and training within first seven working days.
22VAC40-73-640-A: Medication management plan did not include methods to ensure accurate counts of controlled substances.
22VAC40-73-1070-B: Failed to ensure harmful materials or objects were inaccessible to residents with serious cognitive impairment.
Report Facts
Violations cited: 20
Distinct standards: 16
Inspections on page: 11
Inspections with violations: 4
Complaint visits: 1
Individual Reports
One document per inspection visit.
Inspection Report — Sep 8, 2023
Complaint Investigation
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.
Violations (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 — Sep 8, 2023
Routine
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.
Violations (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 — Aug 24, 2021
Routine
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.
Violations (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 — Feb 27, 2020
Routine
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.
Violations (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 |
4 CMS Surveys
CMS Survey — Sep 8, 2023
Sep 8, 2023
CMS Survey — Feb 27, 2020
Feb 27, 2020
CMS Survey — Aug 24, 2021
Aug 24, 2021
CMS Survey — Sep 8, 2023
Sep 8, 2023
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