VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Banister Residential Care Facility, Inc.
1017 Bethel Road
Halifax, VA 24558
(434) 476-8811

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: April 5, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/05/2023 10:00am until 2:30pm. 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: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on resident record review, the facility failed to ensure that the statement that was provided to a resident disclosed all required information about the facility. EVIDENCE: 1. Resident 9 was admitted to the facility on 03/02/2023. The assisted living facility disclosure statement in the record for the resident did not contain information on whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of Correction:	Administrator will add required information to resident chart.
Standard #:	22VAC40-73-150-C
Description:	Based on observations of the facility physical plant and resident and staff record review, the facility administrator failed to be responsible for the general administration and management of the facility and oversee the day-to-day operation of the facility. EVIDENCE: 1. The current inspection conducted on 04/05/2023 resulted in 18 violations of which 9 violations are repeat/systemic in nature in the areas of resident care, employee requirements, staff training of policy and procedures and physical plant.
Plan of Correction:	Administrator is overseeing facility as outlined in her job description. The day-to-day operation is done accordingly. Working short staff having to put patient care first has sometimes caused things to go unnoticed. Administrator is doing what is required under the circumstances faced before her. A plan of correction date was not provided for this violation. The date entered is the date the plan was received by the LI.
Standard #:	22VAC40-73-190-C
Description:	Based on staff record review and staff interview, the facility failed to ensure that prior to staff members being placed in charge that staff members are informed of and receive training on their duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. Interview with staff 4 revealed to the licensing inspectors (LIs) that staff persons 1, 2 and 3 are staff persons that are placed in charge of the facility when staff 4 is not on the premises. The records for staff persons 1, 2 and 3 did not contain evidence of these staff persons receiving training on their duties and responsibilities. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	The administrator will be updating employee charts with the people in charge job duties.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure that each staff person submitted results annually of a tuberculosis (TB) risk assessment documenting that the staff person is free of TB. EVIDENCE: 1. The most recent TB risk assessment in the record for staff 1 was dated 10/21/2021. Interview with staff 4 revealed that staff 1 does not have a TB risk assessment for the year 2022.
Plan of Correction:	Staff TB risk assessment test was done. A plan of correction date was not received for this violation. The date included is the date the plan was received by the LI.
Standard #:	22VAC40-73-310-A
Description:	Based on resident record review and staff interview, the facility failed to ensure no resident was retained who requires a level of care or service or type of service for which the facility is not licensed or which the facility does not provide. EVIDENCE: 1. The facility is licensed for residential living care only. 2. The record for resident 5 contained a public pay uniform assessment instrument (UAI), dated 04/11/2022, which indicates the resident was assessed and met the criteria for residential living. 3. In addition, the record for the resident contained an updated public pay UAI, dated 08/30/2022, that includes the following information: ?Patient is a 71-year-old male that currently lives in an ALF. Patient has had increase in cognitive decline that makes it unsafe for him to continue to live at the facility. Patient is dependent in 4 ADLs, behavior/orientation and medication. Patient is semi-dependent in 1 ADL. Patient meets the functional criteria to qualify for services. Patient has a qualifying medical nursing need per the manual.?, ?Patient frequently leaves facility to go find cigarettes.? and ?Due to his memory loss, and insomnia his movement during the night needs to be monitored. He is a chronic smoker therefore he needs prompt not to take cigarette butts from containers, hygienic prompts are needed on a regular basis, He would benefit from a NF verses the ALF which he lives now.? 4. During on-site inspection conducted on 04/05/2023, it was noted that resident 5 is still currently residing at the facility. This is a repeat violation from the 01/13/2023 and 02/22/2023 inspections.
Plan of Correction:	Administrator clarified these findings with resident 5 PCP. Administrator is still making effort to place resident in nursing home without any success. Administrator will continue to find placement for resident with cognitive impairment and document. UAI dated 4/11/22 resident was classified as residential care until administrator noticed a decline in care and contacted DSS for a updated I-JAI for nursing home placement.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a statement that the individual does not have any prohibited conditions was included in the physical examination. EVIDENCE: 1. The record for resident 3 has a physical examination dated 03/04/2020 that has documentation that the resident requires the prohibited condition ?requires continuous licensed nursing care? checked on the form checked on the form which is a prohibited condition for residing in an assisted living facility. This documentation makes it undeterminable if the residents care needs can be met in the facility. This is a repeat from the 01/13/2023 and 02/22/2023 inspections. 2. The record for resident 5 has a physical examination dated 12/21/2020 that has documentation that the resident requires the prohibited condition ?requires continuous licensed nursing care? checked on the form which is a prohibited condition for residing in an assisted living facility.
Plan of Correction:	The administrator had contacted PCP and had documented information that the required information was sent to PCP and got no response. Resident 3 has had a repeat violation because he must wait to see PCP which is scheduled already. A correction date for this violation was not provided for this violations. The date added is the date the plan of correction was received by the LI.
Standard #:	22VAC40-73-450-H
Description:	Based on resident record review, document review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) for a resident are being provided. EVIDENCE: 1. The ISP for resident 5, dated 08/26/2022, included an identified need that the resident has memory loss and that direct care staff will monitor the resident for safety every hour during the night due to the resident?s cognitive impairment. 2. During on-site inspection on 04/05/2023, staff 4 provided the documents ?Hourly Rounds Report? for resident 5 for the time period of 03/01/2023 through 04/05/2023. The report sheets did not include documentation that a round was made on resident 5 every hour for numerous days throughout 03/01/2023 through 04/05/2023.
Plan of Correction:	Staff is currently doing rounds as scheduled and administrator is checking daily to ensure this documentation is being done accordingly. A correction date was not provided for this violation. The date listed is the date that the plan of corrections was received by the LI.
Standard #:	22VAC40-73-470-A
Description:	Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met. EVIDENCE: 1. The record for resident 9 contained an after-visit summary from the hospital, dated 03/02/2023, that the resident was scheduled to have an appointment with Collateral 3 on 03/14/2023 at 8:15AM. The record for the resident did not contain documentation that the resident had attended this appointment. The LI asked staff 4 if the resident had attended this appointment. Documentation of the appointment was not provided to the LI by the end of the on-site inspection on 04/05/2023. Staff 4 stated to the LI that she was unsure if the resident did or did not attend the appointment.
Plan of Correction:	The administrator spoke with the resident and the resident stated that she didn't go to the appointment because she doesn't want to have the surgery. The patient stated that if she decides to go through with the surgery, she will let me know. Documentation was placed in resident chart. A correction date was not provided for this violation. The date listed is the date that the plan of corrections was received by the LI.
Standard #:	22VAC40-73-520-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that a current activity schedule was posted in a conspicuous place in the facility. EVIDENCE: 1. At approximately 10:12AM during on-site inspection, it was noted by two licensing inspectors (LIs) that the activity schedule that was posted in the facility was dated March 2023.
Plan of Correction:	Administrator did activity schedule before inspectors left the facility and was placed on board during inspection.
Standard #:	22VAC40-73-610-B
Description:	Based on observations of the facility posted menu and interview with staff, the facility failed to record menu substitutions on the posted menu. EVIDENCE: 1. Interview with staff 1 expressed that several menu substitutions had occurred during the current week. The current menu posted in the facility does not have documentation of the food substitutions that were made.
Plan of Correction:	Administrator will ensure cook is aware to put substitutes on schedule. A correction date was not provided for this violation. The date listed is the date that the plan of corrections was received by the LI.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that a medication administration record (MAR) for a resident contained all required components. EVIDENCE: 1. The record for resident 9 contained a physician?s order, dated 03/23/2023, for Albuterol inhale one puff every four hours by inhalation route as needed (PRN). The March 2023 medication administration record (MAR) for resident 9 from 03/25/2023 through 03/31/2023 and the April 2023 MAR does not include information that the aforementioned medication is PRN.
Plan of Correction:	Administrator will verify order with PCP.
Standard #:	22VAC40-73-860-G
Description:	Based on observation, the facility failed to ensure that hot water taps available to residents were maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. EVIDENCE: 1. During on-site inspection on 04/05/2023, one licensing inspector (LI) measured the following hot water temperatures: the hot water tap in the bathroom beside the resident sitting area was recorded at 129 degrees Fahrenheit, the hot water tap in the men?s bathroom was recorded at 127 degrees Fahrenheit and the hot water tap in the women?s bathroom was recorded at 138.7 degrees Fahrenheit.
Plan of Correction:	Administrator will have temperature of water adjusted.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure cleaning supplies and other hazardous materials were in a locked area. EVIDENCE: 1. At approximately 10:30AM, one licensing inspector observed a can of Wizard air freshener and a can of Glade air freshener in the closet in room 6. This is a repeat violation from the 01/13/2023 and 02/22/2023 inspections. 2. At approximately 1:55PM, one LI observed a spray bottle of Dollar General cleaner with bleach sitting in the resident sitting area on a podium with no staff present or around the area.
Plan of Correction:	All staff will ensure cleaning supplies are stored properly. A correction date was not provided for this violation. The date listed is the date that the plan of correction was received by the LI.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the building, the facility failed to ensure the interior of the building was maintained in good repair, kept clean and free of rubbish. EVIDENCE: 1. The ceiling around the air vent in room 7 contained staining and the air vent itself contained staining. This is a repeat violation from the 10/26/2022, 01/13/2023 and 02/22/2023 inspections. 2. The floor around the toilet in the men?s restroom beside room 7 contained multiple areas of staining. This is a repeat violation from the 10/26/2022, 01/13/2023 and 02/22/2023 inspections. 3. The floor around the toilet in the unisex restroom contained multiple areas of staining. This is a repeat violation from the 02/22/2023 inspection. 4. The doorknob on the door to room 5 was noted to be broken/inoperable on the day of inspection.
Plan of Correction:	Maintenance painted air vent in room 7. The floor in the men's bathroom and unisex bathroom has been replaced previously. Will have tile replaced again with a different tile color. Door knob to room 5 was tightened the same day of inspection. A correction date was not provided for this violation. The date listed is the date that the plan of correction was received by the LI.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the building, the facility failed to ensure all fixtures were kept in good repair and condition. EVIDENCE: 1. Several chairs in the facility dining area were noted to have loose cushions on the day of inspection. One chair was noted to have the sharp end of a screw that was sticking up through the cushion.
Plan of Correction:	Maintenance removed chairs from dining are until they can be replaced. A correction date was not provided for this violation. The date listed is the date that the plan of corrections was received by the LI.
Standard #:	22VAC40-73-880-C
Description:	Based on observation, the facility failed to ensure that temperatures in all areas used by residents do not exceed 80 degrees Fahrenheit. EVIDENCE: 1. During on-site inspection on 04/05/2023, it was noted between 1:51PM and 2:20PM that the thermostats in the hallway of the facility were registering 81 degrees Fahrenheit.
Plan of Correction:	Administrator/Maintenance will observe the building to ensure the temperature is below 80 degrees. The day of inspection the degree was 81 degree which was below 80 upon inspectors exiting the building. A correction date was not provided for this violation. The date listed is the date that the plan of correction was received by the LI.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation, the facility failed to ensure that a review of the facility emergency preparedness plan was conducted semi-annually with residents and staff. EVIDENCE: 1. During the on-site inspection conducted on 04/05/2023, the LI requested to review documentation of the facility emergency preparedness semi-annual review. Staff 4 provided a sign in sheet for resident emergency practices that contained resident signatures. No staff signatures were present for a review of the facility emergency preparedness plan. The last facility documentation of a review of their emergency preparedness plan conducted with all staff was dated on 03/01/2022. This is a repeat violation from the 01/13/2023 and 02/22/2023 inspection.
Plan of Correction:	Oversite nurse is updating the emergency preparedness plan and the administrator will ensure residents and staff will review the plan and sign.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff person 3 was hired on 12/21/2022. The results of a criminal history record report for staff person 3 was not obtained until 02/24/2023.
Plan of Correction:	Administrator will ensure criminal report is done within 30 days of employment.