Brandon Oaks Nursing and Rehabilitation Center
3837 Brandon Avenue Sw, Roanoke, VA 24018
Brandon Oaks Nursing and Rehabilitation Center is a nursing home in Roanoke, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating5 of 5
- Last standard health inspectionSeptember 8, 2023 (3 years ago)
- Health citations since February 27, 202013 (Virginia average 39)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 13, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 18, 2026.
CMS has cited this home for F0755 2 times since 2023.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Health inspection on September 8, 2023
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 8, 2023.
CMS has cited this home for F0812 3 times since 2020.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 8, 2023.
CMS has cited this home for F0641 2 times since 2020.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 8, 2023.
Fire safety inspection on September 8, 2023
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on February 26, 2024.
CMS has cited this home for K0291 2 times since 2020.
Citation K0932. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on February 26, 2024.
Health inspection on August 24, 2021
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 24, 2021.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 24, 2021.
CMS has cited this home for F0684 2 times since 2020.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 24, 2021.
Fire safety inspection on August 24, 2021
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 27, 2021.
CMS has cited this home for K0345 2 times since 2020.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 27, 2021.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 27, 2021.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on October 27, 2021.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on November 23, 2021.
CMS has cited this home for K0293 2 times since 2020.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on October 27, 2021.
Citation K0352. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly install and monitor supervisory attachments on automatic sprinkler systems.
CMS lists it as corrected on October 27, 2021.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 27, 2021.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 23, 2021.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2021.
Citation K0325. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on October 27, 2021.
Health inspection on February 27, 2020
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 10, 2020.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 10, 2020.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 10, 2020.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 10, 2020.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 10, 2020.
Fire safety inspection on February 27, 2020
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation K0133. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a two-hour-resistant firewall separation.
CMS lists it as corrected on October 6, 2020.
Citation K0223. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on October 6, 2020.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on October 6, 2020.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on October 6, 2020.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 6, 2020.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 6, 2020.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 6, 2020.
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on October 6, 2020.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (540) 776-2616
- Last standard health inspection
- September 8, 2023 (3 years ago)
- Certified beds
- 62
- Residents per day, on average
- 57.3
- Ownership type
- Non profit - Corporation
- Legal business name
- Virginia Lutheran Homes, INC.
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Virginia average (13 vs 39).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- VIRGINIA LUTHERAN HOMES, INC.Operational/managerial control · not applicable · since 04/01/2014
- DOWNS, CHARLESOperational/managerial control · not applicable · since 08/01/2022
- DURAN-BALLEN, J ESTEBANOperational/managerial control · not applicable · since 05/23/2024
- SANDY, PHILLIPOperational/managerial control · not applicable · since 06/02/2025
Questions
When was Brandon Oaks Nursing and Rehabilitation Center last inspected?
CMS lists September 8, 2023 as the date of its most recent standard health inspection.
How many citations (violations) does Brandon Oaks Nursing and Rehabilitation Center have?
CMS lists 13 health citations since February 27, 2020. CMS also calls these deficiencies.
Has Brandon Oaks Nursing and Rehabilitation Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Brandon Oaks Nursing and Rehabilitation Center?
Its CMS overall star rating is 5 of 5.
Is Brandon Oaks Nursing and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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