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: Aug. 7, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 08/07/2023 9:20am until 11:30am 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 #:	22VAC40-73-150-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 08/07/2023 resulted in 13 violations which include the areas of staffing, first aid, CPR, resident care and physical plant. 8 of the 13 violations cited are repeat/systemic in nature. This is a repeat violation from the 04/05/2023 and 06/13/2023 inspections.
Plan of Correction:	Administrator will implement a preemployment checkoff list. which will prevent unauthorized staff on the schedule. Remove from schedule. A correction date was not received for this violation. The date included is the date that the LI received the plan of correction from the facility.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, employee schedules and staff interview, the facility failed to ensure that at least one staff person who has current certification in first aid was on duty in the building at all times. EVIDENCE: 1. The August 2023 employee schedule, which includes the date of July 31, 2023, has staff 2 listed as the only employee in the building on the 11pm to 7am shift on 07/31/2023, 08/04/2023, 08/05/2023, 08/07/2023, 08/09/2023, 08/11/2023, 08/13/2023, 08/14/2023 and 08/17/2023. 2. During a review of the record for staff 2, hired on 05/08/2023, the LI was unable to locate any documentation in regards to staff 2 being certified in first aid. In an interview with staff 1 on the day of inspection, staff 1 confirmed to both LI?s that staff 2 has been the only employee in the building as per the August 2023 schedule and that they were unaware that staff 2 did not have first aid certification.
Plan of Correction:	Administrator will ensure that at least one staff member with First Aid certification will be on staff on all shifts.
Standard #:	22VAC40-73-260-B
Description:	Based on staff record review, employee schedules and staff interview, the facility failed to ensure that at least one staff person who has current certification in cardiopulmonary resuscitation (CPR) was on duty in the building at all times. EVIDENCE: 1. The August 2023 employee schedule, which includes the date of July 31, 2023, has staff 2 listed as the only employee in the building on the 11pm to 7am shift on 07/31/2023, 08/04/2023, 08/05/2023, 08/07/2023, 08/09/2023, 08/11/2023, 08/13/2023, 08/14/2023 and 08/17/2023. 2. During a review of the record for staff 2, hired on 05/08/2023, the LI was unable to locate any documentation in regards to staff 2 being certified in CPR. In an interview with staff 1 on the day of inspection, staff 1 confirmed to both LI?s that staff 2 has been the only employee in the building as per the August 2023 schedule and that they were unaware that staff 2 did not have CPR certification.
Plan of Correction:	Administrator will ensure that at least one staff member with CPR. Certification will be on staff on all shifts
Standard #:	22VAC40-73-270-3
Description:	Based on staff record review, the facility failed to ensure that aggressive behavior training was provided by a qualified health professional. EVIDENCE: 1. The record for staff 2 has documentation of aggressive behavior training being completed on 05/15/2023. Staff 4 is listed as the individual who conducted the training but there is no documentation of staff 4?s qualifications as a health professional to be able to conduct aggressive behavior training.
Plan of Correction:	Administrator will ensure that only a qualified Health professional will train staff in aggressive behavior. Training. A correction date was not received for this violation. The date included is the date that the LI received the plan of correction from the facility.
Standard #:	22VAC40-73-280-A
Description:	Based on resident and staff record review, employee schedules and staff interviews, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans. EVIDENCE: 1. The individualized service plan (ISPs) for resident 1, dated 05/04/2023 has documentation that they require assistance from a direct care staff person for several ADL needs which includes bathing, dressing, walking, stairclimbing and mobility. 2. The ISP for resident 3, dated 08/26/2022 has documentation that they require assistance from a direct care staff person for several ADL needs which includes bathing, dressing, toileting and hourly monitoring during the night due to cognitive impairment. 3. The August 2023 employee schedule, which includes the date of July 31, 2023, has staff 2 listed as the only employee in the building on the 11pm to 7am shift on 07/31/2023, 08/04/2023, 08/05/2023, 08/07/2023, 08/09/2023, 08/11/2023, 08/13/2023, 08/14/2023 and 08/17/2023. 4. During a review of the record for staff 2, hired on 05/08/2023, the LI was unable to locate any documentation in regards to staff 2?s direct care training/qualifications. A ?Job Position: Patient Direct Care Staff/Nights? form was noted to be signed by staff 2 and in their record. In an interview with staff 1 on the day of inspection, staff 1 expressed that staff 2 was scheduled to take the 40-hour direct care class sometime in July 2023 but as of the day of inspection they have not begun the class. Staff 1 confirmed to both LI?s that staff 2 is not currently direct care certified/trained and has worked in the facility on the 11pm to 7am shift as the only employee in the building.
Plan of Correction:	Administrator will ensure that all direct care staff will. Have adequate training and proof of such training.
Standard #:	22VAC40-73-290-A
Description:	Based on review of the facility employee schedule, the facility failed to ensure that written work schedules contained all required information. EVIDENCE: 1. The facility written work schedule for August 2023 does not include the job classifications for the employees listed on the schedule. 2. The initials for staff 3 were observed on the August 2023 medication administration records for administering medications to residents for several days from 08/01/2023 through 08/07/2023. Interview with staff 1 revealed that staff 3 is administering medications to residents. Staff 3?s name was not included on the August 2023 employee written schedule. This is a repeat violation from the 06/13/2023 inspection.
Plan of Correction:	Administrator will ensure that the staff work schedule will Include all staff and job classification.
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. A public pay uniform assessment instrument (UAI), dated 04/11/2022 for resident 3 indicates the resident was assessed and met the criteria for residential living. 3. An updated public pay UAI, dated 08/30/2022 for resident 3 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 08/07/2023, it was noted that resident 3 is currently still residing at the facility This is a repeat violation from the 01/13/2023, 02/22/2023, 04/05/2023 and 06/13/2023 inspections.
Plan of Correction:	Administrator has contacted two facilities and family Member. Next step is to get ADP involved. as son as possible A correction date was not received for this violations. The date included is the date that the LI received the plan of correction from the facility.
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 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. This is a repeat violation from the 04/05/2023 and 06/13/2023 inspections. 2. The record for resident 1 contained a physical examination, dated 05/08/2023, that has documentation that the resident requires the prohibited condition ?requires continuous licensed nursing care? selected on the form which is a prohibited condition for residing in an assisted living facility. This is a repeat violation from the 06/13/2023 inspection.
Plan of Correction:	Statement showing that individual does not have A prohibited condition will be corrected.
Standard #:	22VAC40-73-520-I
Description:	Based on observations of the facility physical plant, the facility failed to post the current months activity schedule. EVIDENCE: 1. At 9:30am on the day of inspection it was observed that the activity schedule that was posted in the facility was for July 2023. An activity schedule for the current month of August 2023 was not observed to be posted on the day of inspection.
Plan of Correction:	Adminiatrator will ensure that current Activity schedule will be posted
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that the results of procedures ordered by a physician were documented. EVIDENCE: 1. The record for resident 2 has a physician order for blood sugar checks daily. The blood sugar monitoring record for July 2023 for resident 2 does not have the results of the resident?s blood sugar on 07/31/2023.
Plan of Correction:	Administrator will have second staff member Check blood glucose record dailey.
Standard #:	22VAC40-73-860-G
Description:	Based on observations during a tour of the building, 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 08/07/2023, one licensing inspector (LI) noted that the hot water tap in the women?s restroom was measured at 124 degrees Fahrenheit. This is a repeat violation from the 04/05/2023 and 06/13/2023 inspections.
Plan of Correction:	Administrator will ensure that hot water taps to residents is maintained within a range of 105 degrees Fahrenheit of 105 degrees to 120. Corrected A correction date was not received for this violation. The date included is the date that the LI received that plan of correction from the facility.
Standard #:	22VAC40-73-870-A
Description:	the building was maintained in good repair, kept clean and free of rubbish. EVIDENCE: 1. 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, 02/22/2023, 04/05/2023 and 06/13/2023 inspections. 2. The floor around the toilet in the unisex restroom contained multiple areas of staining. This is a repeat violation from the 02/22/2023, 04/05/2023 and 06/13/2023 inspections.
Plan of Correction:	Flooring will be replaced
Standard #:	22VAC40-73-870-E
Description:	Based on observations of the facility physical plant, the facility failed to ensure all fixtures were kept in good repair and condition. EVIDENCE: 1. Several chairs located in the facility dining room were noted to have loose cushions on the day of inspection. This is a repeat violation from the 04/05/2023 and 06/13/2023 inspections.
Plan of Correction:	The administrator will ensure that all fixtures Are kept in good repair and condition. Corrected A correction date was not received for this violations. The date included is the date that the LI received the plan of correction from the facility.