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
Inspection History
8Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
May 26, 2026Inspection
- During the morning of the on-site inspection, the LI performed an audit of the assisted living medication carts.
- 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.
- 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.
- 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.
- 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.
January 13, 2026Complaint survey
May 5, 2025Inspection
May 22, 2024Inspection
- 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.
- 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.
- 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”.
- The record for resident 3 contained prescribed orders for TRAMADOL HCL 50 MG TAB – “Take 1 tablet by mouth twice daily”.
- 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.
- 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).
- 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.
- 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.
June 14, 2023Inspection
- 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.
- 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.
- 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.
August 23, 2022Inspection
June 6, 2022Inspection
- 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.
- 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.
- Staff 2, who was employed on 11/9/2022, obtained first aid training on 2/24/2022. This was noted on 6/6/2022.
June 9, 2021Inspection
- 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.
- 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.
- 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.