01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2023-09-08 | 3 | 2023-09-08 | 2 |
| Cycle 2 | 2021-08-24 | 3 | 2021-08-24 | 11 |
| Cycle 3 | 2020-02-27 | 6 | 2020-02-27 | 8 |
CMS CCN 4953732026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Brandon Oaks Nursing And Rehabilitation Center
3837 Brandon Avenue Sw · Roanoke, VA 24018 · Roanoke County
Certified beds62CMS provider file
Recent citation rows33current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
33 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2023-09-08 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2023-11-082023-09-08 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2023-11-08 · complaint2023-09-08 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-11-082023-09-08 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-02-262023-09-08 · FIREK0932Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2024-02-262021-08-24 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2021-09-242021-08-24 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2021-09-242021-08-24 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2021-09-242021-08-24 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2021-11-232021-08-24 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0325Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0352Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2021-10-272021-08-24 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2021-11-232020-02-27 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2020-04-102020-02-27 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2020-04-102020-02-27 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2020-04-102020-02-27 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2020-04-102020-02-27 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2020-04-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DURAN-BALLEN, J ESTEBANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/23/2024
- DOWNS, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2022
- HICKLIN, JENNIFERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/22/2022
- VIRGINIA LUTHERAN HOMES, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2014
- DOWNS, CHARLESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2022
- DURAN-BALLEN, J ESTEBANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/23/2024
- SANDY, PHILLIPIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/02/2025
- VIRGINIA LUTHERAN HOMES, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2014
- DURAN-BALLEN, J ESTEBANIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/23/2024
- MITCHELL, WILLIAMIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.40per resident day
RN hours0.87per resident day
Weekend nurse hours4.54per resident day
Staff turnover34.6%CMS reported field
06 / LOCAL RECORDS
Open the Roanoke ledger →Other published facilities nearby
Davis And Mcdaniel Veterans Care Center180 beds · CMS overall 5/520 citation rowsFriendship Health And Rehab Center253 beds · CMS overall 4/533 citation rowsFriendship Health And Rehab Center - South120 beds · CMS overall 3/536 citation rowsOld Southwest Health And Rehabilitation130 beds · CMS overall 1/5156 citation rowsOur Lady Of The Valley70 beds · CMS overall 4/537 citation rowsPheasant Ridge Nursing And Rehabilitation101 beds · CMS overall 2/547 citation rowsRaleigh Court Health And Rehabilitation Center120 beds · CMS overall 4/548 citation rowsSouth Roanoke Nursing And Rehabilitation98 beds · CMS overall 3/559 citation rows