8
Inspections
On record
5
With violations
Visits that cited something
3
Clean visits
Nothing cited
11
Violations cited
Individual findings
11
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Brandon Oaks was inspected 8 times between June 9, 2021 and May 26, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 11 violations under 11 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 7 of these 8 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
08/09/2026
Administrator
Jessica White
Licensing inspector
Holly Copeland
Inspector phone
(540) 309-5982
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

8

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 26, 2026Inspection1 violation
Inspection dates
05/26/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/26/2026 from 08:30 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure that medications shall remain in the pharmacy issued container with the prescription label or direction label attached.
Evidence
  1. During the morning of the on-site inspection, the LI performed an audit of the assisted living medication carts.
  2. At approximately 09:50AM, while auditing the 1st floor medication cart, the LI and staff 2 observed a box of TESTOSTERONE GEL 1.62% that did not contain a prescription or direction label. Upon further observation, the bottle inside of the box also did not contain a prescription or direction label.
  3. An interview with staff 2 at that time revealed that the TESTOSTERONE GEL 1.62% belonged to resident 9, which was also confirmed by a review of that resident’s current physician’s orders and the corresponding CONTROLLED SUBSTANCE RECORD page.
  4. During the 1st floor medication cart audit, staff 2 confirmed to LI that there was no prescription or direction label on the box of TESTOSTERONE GEL 1.62% nor on the bottle inside.
  5. As a result, the LI notified staff 4 of that observation, and a subsequent interview with staff 4 confirmed that neither the box nor the bottle of TESTOSTERONE GEL 1.62% in the 1st floor medication cart contained a pharmacy or direction label.
Plan of correction
Not published by VDSS.
January 13, 2026Complaint survey0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 64584 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/13/2026 from 12:00 PM to 12:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/08/2025 regarding allegations in the area(s) of: STAFFING AND SUPERVISION RESIDENT CARE AND RELATED SERVICES BUILDINGS AND GROUNDS Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector, at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2025Inspection0 violations
Inspection dates
05/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2025 from 08:30 AM to 01:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2024Inspection3 violations
Inspection dates
05/22/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 from 08:30 AM until 02:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on observation and staff interview, the facility failed to ensure that a medicine cabinet, container, or compartment that is used for storage of facility-administered medications and dietary supplements prescribed for residents is locked and the individual responsible for medication administration shall keep the keys to the storage area on his/her person.
Evidence
  1. During the medication pass observation on 05/22/2024, the date of inspection, at approximately 09:30 AM, this LI observed staff 1 in the hallway preparing medications to administer to resident 4 in his room. After all scheduled medications for resident 4 were dispensed into the medication cup, staff 1 entered the room for resident 4 as this LI was finishing taking notes. As this LI looked up from notes, it was observed that the medication cart that was used to prepare the medications for resident 4 was left unlocked when staff 1 entered his room. This LI pressed in the lock to secure the cart before entering resident 4’s room to observe the medication pass. Upon exiting the resident’s room, this LI informed staff 1 that she had left the medication cart unlocked when she walked away. Staff 1 indicated that she thought she had locked it before she left.
  2. While staff 1 finished administering medications on the rest of the same hall, this LI returned to the nurse’s station area on the same floor to perform medication cart audits of the two carts that were stationary at that location. As this LI approached the medication cart that is designated for rooms 526-540, this LI observed the keys laying on top of that cart in the plastic basket and that the cart was unlocked; therefore, this LI began the audit for that cart. While performing that audit, staff 1 returned with the third medication cart and this LI informed her that when this LI approached it, the keys were laying on top of the cart that is designated for rooms 526-540 and that it was unlocked.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on record review and observation, the facility failed to implement a portion of its medication management plan, specifically regarding methods for monitoring medication administration and the effective use of medication administration records (MARs) for documentation.
Evidence
  1. The facility’s current medication management plan that was last updated on 08/01/2022, under PREPARATION AND ADMINISTRATION, states “A written paper MAR will be written clearly and legibly”. The same medication management plan, under PREPARATION OF MEDICATIONS FOR ADMINISTRATION, regarding administered medications, states “Every administration will be recorded immediately on the resident’s EMAR” and the medication administration record will be “initialed by the person administering the medication”.
  2. The record for resident 3 contained prescribed orders for TRAMADOL HCL 50 MG TAB – “Take 1 tablet by mouth twice daily”.
  3. The corresponding controlled drug narcotic administration written record indicated 9 pills in the inventory for this medication; however, the actual pill card for this same medication contained 8 pills.
  4. This LI inquired to staff 1 as to the reason for the discrepancy in the narcotic medication administration written record and the actual pills in the card, and staff 1 revealed that she had forgotten to sign the narcotic medication administration written record when she administered the TRAMADOL 50 MG TAB to resident 3 at 08:00 AM on the morning of inspection (05/22/2024).
Plan of correction
Not published by VDSS.
22VAC40-80-120-E-2
Based on observation, staff interview, and the regulations for GENERAL PROCEDURES AND INFORMATION FOR LICENSURE, the facility failed to ensure that the findings of the most recent facility inspection were posted on the premises.
Evidence
  1. While performing the physical plant observation on the date of inspection, this LI observed that the yellow Acknowledgment of Inspection form, dated 06/14/2023, was posted in a clear plastic sleeve in the common area outside of the dining room; however, the actual results (violations) of that inspection were not posted.
  2. The interview at that time with staff 4 did not result in locating the posted results of the 06/14/2023 inspection within the facility.
Plan of correction
Not published by VDSS.
June 14, 2023Inspection2 violations
Inspection dates
06/14/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2023 from 08:30 AM until 02:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. At approximately 9:18AM during on-site inspection, collateral 1 noted that the door to the housekeeping room on the third floor was unlocked and unattended. Collateral 1 noted a container of Diversey tile and grout rejuvenator and a container of Diversey sanitizer located in the bottom of the gray cabinet located in the back corner of the room.
  2. At approximately 12:19PM, collateral 1 noted that the door to the housekeeping room on the third floor was still unlocked and unattended and the two aforementioned items were still located in the gray cabinet.
Plan of correction
On the day of inspection, it was discovered that the 3rd floor housekeeping closet handle was locked but the door had to be pulled shut forcefully for the door to latch and fully lock. This issue was addressed and corrected on the day of inspection.
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that medications were stored in a locked area.
Evidence
  1. On the date of inspection at 08:45 AM, LI and collateral 1 observed an unlocked cart containing medications to be sitting inside of the open conference room that was being utilized for the inspection. There were no staff observed around the cart. Staff 5 was also brought in to observe the unlocked cart.
Plan of correction
On day of inspection, a new process was implemented for the overflow med cart to ensure that the oncoming and off going nurse check that the overflow med cart is locked. All nurses were educated on the new process. Clinical Manager will audit periodically for compliance.
August 23, 2022Inspection0 violations
Inspection dates
08/23/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/23/2022, 9:10 am to 9:55 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7/29/2022 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: one attempted Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 6, 2022Inspection3 violations
Inspection dates
06/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
The facility requested information regarding timing of medication administration times. LI will email it to the facility. There was a discussion regarding various practices of documenting narcotic counts at change of shift.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/6/2022, 8:45 am to 2 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
22VAC40-73-220-A
Based on staff record review, the facility failed to have some required information in the record for private duty personnel.
Evidence
  1. The record for staff 4, who is a private duty companion for resident 7, lacks information regarding information on the type and frequency of the services to be delivered to the resident by private duty personnel.
Plan of correction
Administrator or designee will ensure all private duty files are complete prior to beginning services and will audit files periodically to ensure compliance.
22VAC40-73-680-C
Based on observation and resident record review, the facility failed to administer medications within one hour of the scheduled time.
Evidence
  1. Resident 2 had several medications scheduled to be administered at 8 am, and on the day of the inspection, they were administered at 9:35 am. The medications were: Lisinopril, Magnesium Oxide, Aspirin, Calcium, and Eye Multivitamins.
Plan of correction
Nursing staff was educated on the med management policy regarding medication administration times on the day of inspection. Clinical Manager will do periodic audits to ensure medications are being administered on time.
22VAC40-73-260-A
Based on staff record review, the facility failed to ensure a new direct care staff person had first aid training within 60 days of hire.
Evidence
  1. Staff 2, who was employed on 11/9/2022, obtained first aid training on 2/24/2022. This was noted on 6/6/2022.
Plan of correction
Administrator or designee will ensure all staff obtain first aid training within 60 days of hire and will audit employee files periodically to ensure compliance.
June 9, 2021Inspection2 violations
Inspection dates
June 9, 2021 and June 10, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/10/2021 and concluded on 6/11/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 39. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, health department report, medication management plan, and infection control policy submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-100-C-2
Based on document review, the facility's infection control plan did not fully address a required section of the plan.
Evidence
  1. The part of the facility's plan entitled INJECTABLE MEDICATION ADMINISTRATION does not address the use of safe injection practices and other procedures where the potential for exposure to blood or body fluids exists.
Plan of correction
The Injectable Medication Administration policy will be updated to address the use of safe injection practices and other Plan of Correction: The Injectable Medication Administration policy will be updated to address the use of safe injection practices and other procedures where the potential for exposure to blood and bodily fluids exits.
22VAC40-73-440-A
Based on resident record review, the facility failed to complete uniform assessment instruments (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110).
Evidence
  1. The UAI for resident 1 dated 05/04/2021 has two entries for mobility. Both Mechanical & Human Help with Supervision and Confined Moves About were selected.
  2. The UAI for resident 2 dated 04/27/2021 has two entries for mobility. Both Mechanical & Human Help with Supervision and Confined Moves About were selected.
Plan of correction
The mobility section of the UAI for resident 1 has been updated and is accurate. The mobility section of the UAI for resident 2 has been updated and is accurate.