Cycle 1
Health 2023-09-08 · Fire 2023-09-08
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Roanoke, VA
Brandon Oaks Nursing And Rehabilitation Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3837 Brandon Avenue, Roanoke, VA
(540) 776-2616
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.81
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.37
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.53
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
5.87
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
327
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0238
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.96
Baseline 21.14% · Performance 17.28% · Measure score 8.96 · Achievement 8.96 · Improvement 8.89
Healthcare-associated infections
7.21
Baseline 7.09% · Performance 5.68% · Measure score 7.21 · Achievement 7.21 · Improvement 6.23
Total nurse turnover
4.2
Baseline 58.82% · Performance 46.51% · Measure score 4.2 · Achievement 4.2 · Improvement 3.12
Adjusted total nurse staffing
8.89
Baseline 6.53 hours · Performance 5.61 hours · Measure score 8.89 · Achievement 8.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.63% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 314 · Observed rate 5.41% · Lower 95% interval 6.03% |
| Discharge to community | 64.4% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 343 · Observed rate 65.6% · Lower 95% interval 60.47% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.77% |
95.27%
2.5 pts worse
|
Numerator 154 · Denominator 166 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 166 |
| Discharge self-care score | 69.4% |
53.69%
15.7 pts better
|
Numerator 93 · Denominator 134 |
| Discharge mobility score | 72.39% |
50.94%
21.5 pts better
|
Numerator 97 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 3.01% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 166 · Adjusted rate 3.45% |
| Healthcare-associated infections requiring hospitalization | 5.68% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 2.78% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 6.41% |
8.2%
1.8 pts worse
|
Numerator 23 · Denominator 359 |
| Staff flu vaccination coverage | 96.74% |
42%
54.7 pts better
|
Numerator 415 · Denominator 429 |
| Discharge function score | 74.63% |
56.45%
18.2 pts better
|
Numerator 100 · Denominator 134 |
| Transfer of health information to provider | 83.02% |
95.95%
12.9 pts worse
|
Numerator 88 · Denominator 106 |
| Transfer of health information to patient | 77.78% |
96.28%
18.5 pts worse
|
Numerator 35 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 38.78% |
25.2%
13.6 pts better
|
Numerator 38 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
91.2%
7.4 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.4% · Q4 97.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
94.0%
1 pts better
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.6%
0.1 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.8% · Q3 2.6% · Q4 3.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
15.7%
13.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.4% · Q3 2.9% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.7%
1.5 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.5% · Q3 8.8% · Q4 7.1% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
20.2%
7.6 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 12.5% · Q3 11.8% · Q4 3.6% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
15.0%
8.2 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.8% · Q3 23.1% · Q4 29.2% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.2% |
17.5%
2.7 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.9% |
15.7%
5.2 pts worse
|
14.9%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 27.6% · Q3 28.1% · Q4 12.0% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
1.6%
4.7 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 10.3% · Q4 9.1% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
22.2%
3.2 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 28.5% · Q3 22.4% · Q4 32.0% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.2%
2.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 0.0% · Q4 8.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
74.6%
20.5 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 92.9% · Q3 95.6% · Q4 99.2% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.7%
5.4 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.1% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
73.6%
21.5 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.0%
1.2 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 15.3% · Expected 17.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-24 · Fire 2021-08-24
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-26
D · Potential for more than minimal harm
2023-09-08
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-26
F · Potential for more than minimal harm
2021-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-27
F · Potential for more than minimal harm
2021-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-27
F · Potential for more than minimal harm
2021-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-10-27
F · Potential for more than minimal harm
2021-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-10-27
E · Potential for more than minimal harm
2021-08-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-23
E · Potential for more than minimal harm
2021-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-10-27
E · Potential for more than minimal harm
2021-08-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-10-27
E · Potential for more than minimal harm
2021-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-27
E · Potential for more than minimal harm
2021-08-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-23
D · Potential for more than minimal harm
2021-08-24
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2021-10-27
D · Potential for more than minimal harm
2021-08-24
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-10-27
F · Potential for more than minimal harm
2020-02-27
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-02-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-10-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-09-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-08
F · Potential for more than minimal harm
2021-08-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-09-24
E · Potential for more than minimal harm
2020-02-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-10
D · Potential for more than minimal harm
2020-02-27
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2020-04-10
D · Potential for more than minimal harm
2020-02-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-04-10
D · Potential for more than minimal harm
2020-02-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-10
D · Potential for more than minimal harm
2020-02-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-04-10
D · Potential for more than minimal harm
2020-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-10
Penalties and ownership
What sits behind the stars
Ownership
Downs, Charles
Operational/Managerial Control · Individual
Downs, Charles
Corporate Officer · Individual
Duran-Ballen, J Esteban
Operational/Managerial Control · Individual
Duran-Ballen, J Esteban
Corporate Director · Individual
Hicklin, Jennifer
Corporate Officer · Individual
Sandy, Phillip
Operational/Managerial Control · Individual
Virginia Lutheran Homes, Inc.
Operational/Managerial Control · Organization
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#2
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#3
Raleigh Court Health And Rehabilitation Center
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