Virginia DSS · Assisted Living Facility

Brandon Oaks Intensive Assisted Living

📍 3837 Brandon Avenue, Roanoke, VA, 24018

ID 40838One Year licenseActive
11
Inspections
On record
4
With violations
Visits that cited something
7
Clean visits
Nothing cited
20
Violations cited
Individual findings
16
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Brandon Oaks Intensive Assisted Living was inspected 11 times between September 27, 2021 and May 6, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 20 violations under 16 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
07/22/2026
Administrator
Esteban Duran-Ballen
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

11

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

May 6, 2026Inspection0 violations
Inspection dates
05/06/2026
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 IMPAIRMENTS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 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: 05/06/2026 08:25 to 14:30 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication Pass Observation, Medication Cart Audit, Morning and Afternoon Activities, Breakfast Meal 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 Angela Swink, Licensing Inspector at 276-623-6575or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 29, 2025Inspection0 violations
Inspection dates
07/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 7/29/2025 13:00 to 13:40 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 7/21/2025 regarding allegations in the area(s) of: Resident Care and Related Services, and Safe, Secure Environment Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2025Inspection2 violations
Inspection dates
04/28/2025
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 PREPAREDNESS22VAC40-73 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: 04/28/2025 from 08:45 AM to 03:00 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: 23 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: N/A Number of interviews conducted with staff: 3 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. 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
22VAC40-73-550-G
Based on record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. of this review shall be the resident’s, his legal representative’s or responsible individual’s, written acknowledgement of having been so informed, which shall include the date of the review, and shall be filed in the resident’s record. EVIDENCE:
  2. On the date of inspection, the record for resident 2, admitted 01/23/2024, did not contain documentation of an annual review of resident rights with the resident, his legal representative, or responsible individual for 2025.
  3. On the date of inspection, the record for resident 3, admitted 04/01/2024, did not contain documentation of an annual review of resident rights with the resident, his legal representative, or responsible individual for 2025.
  4. An interview with staff 5 on the date of inspection was unsuccessful at locating a 2025 resident rights review for resident 2 and resident 3 or their legal representatives or responsible individuals.
Plan of correction
Corrective Actions: • Resident #2 and Resident #3’s legal representatives were provided with the current resident rights review, and signed acknowledgments were obtained. Audit: • A full audit of all resident files was completed to ensure compliance community-wide. Staff training: • The admissions and care coordination teams received retraining on annual documentation requirements for resident rights. Monitoring: • The administrator or designee will complete quarterly internal audits to ensure compliance with resident rights acknowledgement requirements.
22VAC40-73-640-A
Based on observation, record review, and staff interview, the facility failed to implement portions of its medication management plan with regard to its standard operating procedures and its methods for monitoring medication administration.
Evidence
  1. The facility’s medication management plan that was provided by staff 5 on the date of inspection indicates that it was last reviewed on 01/2025, and staff 5 confirmed that this is the most current version. Under the ADMINISTRATION SCHEDULE chart, section N, point #7, the medication management plan states that “the med cart is always visible to the staff person during the med pass and is kept locked in between residents”.
  2. On the date of inspection, LI observed staff 1 walk away from the unlocked medication cart to administer medication to resident 5 at approximately 11:50 AM. This LI observed staff 1 push the unlocked medication cart down the hall and at approximately 11:55 AM, LI observed staff 1 walk away from the unlocked medication cart to administer eye drops to resident 6. This LI then interviewed staff 1 about the facility’s procedures when administering medications, and staff 1 stated that she had unintentionally left the medication cart unlocked when administering medication to resident 5 and eye drops to resident 6.
  3. The medication management plan provided by the facility under section RECEIPT OF MEDICATION states that “all medications shall remain in the pharmacy-issued container, with the legible prescription label attached, until administered”.
  4. While performing a medication cart audit with staff 1 on the date of inspection, at 12:23 PM, LI observed two loose pills on the left side in the 2nd drawer down. One pill was a large oblong gel tab that was yellow in color. The other was a smaller round light pink pill with the inscription “SG”.
Plan of correction
Corrective Actions: • The loose pills discovered during the inspection were immediately removed and properly discarded according to facility protocol. Staff training: • All medication administration staff received re-education on the facility’s medication management plan, including the requirement to lock the med cart when unattended and to ensure that all medications remain in pharmacy-labeled containers. Monitoring: • Director of nursing or designee will perform a medication pass observation with all medication administration staff to ensure compliance with the medication management plan.
November 20, 2024Inspection0 violations
Inspection dates
11/20/2024
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: 11/20/2024 12:00 to 12:30 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 11/11/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 26, 2024Complaint survey0 violations
Inspection dates
06/26/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/26/2024 11:50 to 13:10 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 6/26/2024 regarding allegations in the area(s) of: Admission, Discharge, and Retention of residents, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 22 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 Angela Swink, Licensing Inspector at 276-625-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 21, 2024Inspection1 violation
Inspection dates
05/21/2024
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 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 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: 5/21/2024 9:15am to 3:00pm 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: 24 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: 3 Number of interviews conducted with staff: 4 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-490-A-2
Based on staff interview, the 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 the facility employs a licensed health care professional who is on site on a full-time basis.
Evidence
  1. During an interview on 5/21/2024 with the licensing inspector and staff person 1, staff person 1 disclosed that the facility was not able to locate the binder with the documentation for any of the completed health care oversights for verification of completion that 1 was completed within the last 6 months by the licensed healthcare professional.
Plan of correction
A new health care oversight will be completed by the director of nursing or designee for all residents by June 28th, 2024. The director of nursing or designee will be in-serviced by the administrator to ensure this is completed every 6 months going forward.
April 2, 2024Inspection0 violations
Inspection dates
04/02/2024, 04/04/2024
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 04/02/2024 12:20pm to 12:52pm, 04/04/2024 09:00 to 09:06am 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 03/29/2024 regarding allegations in the area(s) of: Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments Number of residents present at the facility at the beginning of the inspection: 21 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 staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2023Inspection11 violations
Inspection dates
05/22/2023
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: 05/22/2023 from 08:45 AM until 02:45 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
22VAC40-73-1100-A
Based on resident record review and staff interview, the facility failed to obtain written approval of one the required persons prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.
Evidence
  1. The census report provided during on-site inspection on 05/22/2023 by staff 4 and the record for resident 1 contains documentation that the resident was admitted to the facility on 04/17/2023.
  2. The approval for placement in a special care unit document was not signed by the resident’s spouse until 04/27/2023 giving approval for the resident to be placed in a safe, secure environment.
  3. Interview with staff 4 confirmed that the aforementioned information is accurate.
Plan of correction
Not published by VDSS.
22VAC40-73-190-C
Based on record review, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities.
Evidence
  1. The record for staff 1, hired 06/30/2020, did not contain evidence that staff 1 had been informed of duties and responsibilities and provided written documentation of such duties.
  2. Interview with staff 4 and 5 indicated that there are shifts where staff 1 could be in charge.
Plan of correction
Not published by VDSS.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility that all required personal and social information on a person was obtained.
Evidence
  1. The resident – personal/social data document for resident 1 did not include information regarding the resident’s current behavioral and social functioning regarding strengths and problems on page 2 of 2.
Plan of correction
Not published by VDSS.
22VAC40-73-250-C
Based on record review, the facility failed to ensure that certain personal and social data is to be maintained on staff and included in the staff record.
Evidence
  1. The record for staff 1, hired 06/30/2020, did not contain verification that the staff person has received a copy of his current job description.
Plan of correction
Not published by VDSS.
22VAC40-73-310-D
Based on resident record review and staff interview, the facility failed to ensure, based upon review of the uniform assessment instrument (UAI), that the administrator provided written assurance to a resident that the facility has the appropriate license to meet his care needs at the time of admission.
Evidence
  1. The census report provided during on-site inspection on 05/22/2023 by staff 4 and the record for resident 1 contains documentation that the resident was admitted to the facility on 04/17/2023.
  2. The record for resident 1 contains documentation that written assurance was not provided to the resident and/or the resident’s legal representative until 04/27/2023.
  3. Interview with staff 4 confirmed that the aforementioned information is accurate.
Plan of correction
Not published by VDSS.
22VAC40-73-1090-A
Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, all residents were assessed as having a serious cognitive impairment (SCI) due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident 1 was admitted to the facility on 04/17/2023 and the undated assessment of serious cognitive impairment form (ASCI) for resident 1 indicated that resident 1 can recognize danger or protect his or her own safety and welfare.
  2. Resident 4 was admitted to the facility on 12/23/2022 and the ASCI for resident 4, dated 12/21/2022, indicated that resident 4 can recognize danger or protect his or her own safety and welfare.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on observation during medication cart audit and policy review, the facility failed to ensure that it implemented a portion of its medication management plan.
Evidence
  1. The facility’s medication management plan, with an effective date of June 2022, indicates that controlled drugs will be counted each shift by nursing staff coming on with the nursing staff going off to ensure accurate counts of all controlled medications.
  2. During the audit of the facility’s medication cart, it was noted by two licensing inspectors (LIs) that from 05/01/2023 until the date of inspection on 05/22/2023, there was no documentation to indicate that staff coming on duty for their shifts have been counting with off-going staff every shift.
Plan of correction
Not published by VDSS.
22VAC40-73-270-1
Based on record review and staff interview, the facility failed to ensure that for staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive or restrained, that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents; This training shall include, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior.
Evidence
  1. The record for staff 1, hired 06/30/2020, did not contain documentation or evidence of an annual refresher training in aggressive behaviors.
  2. The record for staff 3, hired 04/05/2023, did not contain documentation or evidence that the staff member had received aggressive behavior training prior to being involved in the care of such residents. LI observed staff 3 on-duty during the on-site inspection.
  3. The record for staff 2, hired 02/27/2023, did not contain documentation or evidence that staff 2 has had training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
  4. Interview with staff 4 revealed that the most recent aggressive behavior training that was scheduled in March 2023 had been canceled by the provider and the facility has been unable to find another provider since that time as of the date of inspection on 05/22/2023.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. The record for resident 2, admitted 12/09/2021, did not contain documentation of an annual review of resident rights since admission.
  2. The record for resident 3 contained documentation that the most recent resident rights review was conducted with the resident and/or the resident’s legal representative on 04/10/2020 and with resident 5 and/or the resident’s legal representative on 02/02/2021.
  3. Interview with staff 4 confirmed that this is accurate.
Plan of correction
Not published by VDSS.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed as required.
Evidence
  1. The UAI for resident 1, dated 04/14/2023, did not contain the signature of the administrator or designee on page 2. This was also noted by staff 4.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that an individualized service plan (ISP) for a resident contained all required components.
Evidence
  1. The ISP for resident 3, dated 11/30/2022, indicates that the resident has someone with them during waking hours and that individual can assist with eating, toileting, and advocating for the resident.
  2. Interview with staff 4 revealed that the resident does have private duty aides, whenever they are available from collateral 2; however, the private duty individual(s) from collateral 2 are not listed on the resident’s ISP as a companion services provider to resident 3.
Plan of correction
Not published by VDSS.
September 29, 2022Inspection0 violations
Inspection dates
09/29/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 BUILDINGS AND GROUND
Technical assistance
610
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: 09/29/2022 11:00 AM – 12:00 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 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.
June 14, 2022Inspection6 violations
Inspection dates
06/14/2022
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 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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
860-G, 1110-A
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: 06/14/2022 09:00 AM – 04:00 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-D
Based on observation, the facility failed to ensure that any operable window (i.e., a window that may be opened) shall be effectively screened.
Evidence
  1. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that operable windows were not screened in any of the resident rooms.
Plan of correction
Facility installed screens on all operable windows within unit.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained all required components.
Evidence
  1. The uniform assessment instrument (UAI) for resident 1, dated 11/30/2021, indicated that the resident is disoriented to some spheres, all the time to time and place; however, the ISP for the resident indicated that the resident is disoriented to some spheres, all the time to time, place and situation.
  2. Interview with staff 4 and 5 revealed that the UAI is correct and the ISP is incorrect.
  3. The UAI for resident 5, dated 11/30/2021, indicated that the resident requires mechanical help and supervision human help with wheeling; however, the ISP for the resident, dated 12/07/2021, indicated that the resident is independent with wheeling. Also, the UAI for the resident indicated that the resident requires mechanical help and physical human assistance with mobility; however, the ISP for the resident indicated that the resident requires mechanical/supervision human assistance with mobility.
  4. Interview with staff 4 and 5 revealed that the UAI is correct and the ISP is incorrect.
Plan of correction
Corrections were made to the ISPs for residents #1 and #5. Director of Nursing will complete random audits of the UAIs and ISPs monthly to ensure compliance and accuracy of all UAIs and ISP information.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive first aid certification within 60 days of employment.
Evidence
  1. The record for staff 3, hired 03/30/2022, did not contain any documentation that staff 3 has obtained first aid certification.
  2. Interview with staff 4 and 5 indicated that staff 3 does not have current first aid certification.
Plan of correction
1. Staff member 3 received first aid certification. 2. Administrator or designee will audit all CNA and nurse employee files for First aid and CPR certifications 4 weeks post hire and annually to verify completion.
22VAC40-73-120-A
Based on record review, the facility failed to ensure that all staff shall receive the orientation and training as required in subsections of this regulation within the first seven working days of employment.
Evidence
  1. The record for staff 3, hired 03/30/2022, did not contain documentation that the staff member had received the required orientation and training within seven days of employment.
  2. Interview with staff 4 and 5 indicated that staff 3 did not receive the specific orientation and training as required.
Plan of correction
1. Staff member 3 was oriented using facility form to document orientation. Orientation for staff member 3 was redone using DSS model form. 2. Facility implemented use of DSS model form for all new hire orientations.
22VAC40-73-640-A
Based on document review, the facility’s medication management plan did not contain all required components.
Evidence
  1. The facility’s medication management plan provided during inspection, dated 12/07/2021, did not include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Plan of correction
The Director of nursing will update the facility’s medication management plan to include all regulation requirements including the procedure to ensure accurate counts of all controlled substances.
22VAC40-73-1070-B
Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that the overhead cabinet in the bathroom of room 312 was unlocked and contained Dove deep moisture body wash, Tom’s of Maine deodorant, Neutrogena Healthy Scalp shampoo, and Gold Bond eczema relief cream.
  2. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that the overhead cabinet in the bathroom of room 313 was unlocked and contained hand sanitizer gel, DermaRite PeriGuard ointment, Degree deodorant, Freshscent roll-on deodorant, VO5 shampoo, Suave shampoo + conditioner, DermaRite moisturizing lotion, DermaRite perineal cleanser, and milk and honey hand wash.
  3. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed an activity area which contained numerous activity supplies in various unlocked cabinets. One unlocked cabinet contained a plastic bin of various colors of nail polish and polish remover. Another unlocked cabinet contained an unlocked plastic bin of various craft paints, brushes, and buttons, and another open plastic bin of additional craft paints, pipe cleaners, and small decorative pom-poms.
Plan of correction
1. All identified materials and/or object that may be harmful to a resident with serious cognitive impairment were removed and immediately placed in a lockable/secure location. 2. Facility installed hidden protective locks on all accessible cabinets throughout unit to ensure cabinets automatically lock after use.
September 27, 2021Inspection0 violations
Inspection dates
09/27/2021
Areas reviewed
None
Technical assistance
NOTE: At the date of this inspection, the facility is undergoing renovations to become a secured memory care facility; therefore, no residents are in the facility during this process. Certain documentation for staff members who will work in the secured memory care facility was reviewed during the current inspection. Once the renovation is complete, the facility is aware that an on-site Licensing inspection must occur prior to admitting any residents to ensure compliance with Assisted Living Facility regulations with regard to a Safe, Secure Environment.
Comments
A renewal inspection was initiated on 9/24/2021 and concluded on 9/29/2021. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 0. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 0 resident records, 3 staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, and the staff roster submitted by the facility to ensure that documentation was complete. The Licensing Inspector will conduct the on-site portion of the inspection once facility renovations are complete. An exit interview will be conducted with the Administrator and Director of Nursing upon completion of the on-site inspection, where findings will be reviewed and an opportunity will be given for questions, as well as for providing any information or documentation which is not available during the inspection. The information gathered during the current inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.