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: Oct. 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/05/2023 9:30am until 12:00pm 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: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 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 #:	22VAC40-73-150-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 10/05//2023 resulted in 13 violations which include the areas of staffing, admission, retention and discharge, resident care and related services and physical plant. 9 of the 13 violations cited are repeat/systemic in nature. This is a repeat violation from the 04/05/2023, 06/13/2023 and 08/07/2023 inspections.
Plan of Correction:	Administrator will ensure that care is provided to residents in a manner Will protect their health, safety, and will being. The Medication Administration Records, Glucose and Blood Pressure records will be reviewed. At the beginning of each shift to ascertain all data has been entered. The facility will be inspected daily by staff. Completed. A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.
Standard #:	22VAC40-73-250-A
Description:	Based on staff record review, the facility failed to ensure that a record was established for each staff person. EVIDENCE: 1. The LI requested to review that record for staff on the day of inspection. In an interview conducted with staff 1 on the day of inspection, staff 1 expressed that their first day of work was 10/02/2023 but as of the day of inspection they do not have a staff record established.
Plan of Correction:	Administrator will ensure that a record shall be established for Each staff person. 10/5/23
Standard #:	22VAC40-73-250-B
Description:	Based on staff record review, the facility failed to ensure that all staff records are maintained at the facility. EVIDENCE: 1. The LI requested to review the record for staff 3 during the on-site inspection conducted on 10/05/2023. Staff 1 expressed that they could not locate the record for staff 3 in the facility on the day of inspection.
Plan of Correction:	Administrator will ensure that all staff records shall be retained at The facility, treated confidentially and kept in a locked Area. 11/14/23
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 5 is listed as the individual who conducted the training but there is no documentation of staff 5?s qualifications as a health professional to be able to conduct aggressive behavior training. This is a repeat violation from the 08/07/2023 inspection.
Plan of Correction:	Administrator will ensure that staff will be trained By a qualified health professional. 10/30/23
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. In an interview with staff 4 during the on-site inspection it was expressed that staff 2 works the 11pm to 7am shift in the facility and that they are the only employee in the building during the shift. This was also confirmed in an interview with staff 1 during the on-site inspection. 4. During a review of the record for staff 2, hired on 05/08/2023, the LI was unable to locate any documentation in regard 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. Staff 1 confirmed to both LI?s that staff 2 is not currently direct care certified/trained. This is a repeat violation from the 08/07/2023 inspection.
Plan of Correction:	Administrator will ensure that all staff will have adequate Knowledge, skills, and abilities to provide needed skills. Staff 2 will be terminated if training is not completed 10/30/23 The Individualized service plan for Resident 1 will be updated To reflect that he does not require assistance for staff for walking Or mobility and very little for dressing. 10/23/23
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. 1. The facility written work schedule for September 2023 does not include the job classifications for all employees listed on the schedule. 2. The September 2023 employee schedule does not have documentation of any staff scheduled to work the 11pm to 7am shift on 09/01/2023 through 09/04/2023, 09/07/2023, 09/10/2023, 09/14/2023 and 09/17/2023 through 09/30/2023. 3. The initials for staff 6 were observed on the September 2023 medication administration records for administering medications to residents for multiple days from 09/01/2023 through 09/30/2023. Staff 6?s name was not included on the September 2023 employee written schedule for all days that the employee worked. This is a repeat violation from the 06/13/2023 and the 08/07/2023 inspection.
Plan of Correction:	Administrator will ensure that that a written work schedule that includes The names and job classification will be maintained at all times. Completed A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.
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 an on-site inspection conducted on 10/05/2023, 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, 06/13/2023 and 08/07/2023 inspections.
Plan of Correction:	Administrator will ensure the facility will not retain residents For which it cannot provide or secure appropriate care. Administration has diligently been pursuing facilities to admit Resident 3 and will continue to do so. Assistance from Social Service has also been sought. A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.
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, 06/13/2023 and 08/07/2023 inspections.
Plan of Correction:	Administrator will ensure that all pertinent information is included inThe physical examination by thoroughly reviewing the data.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that all residents of Assisted Living Facilities (ALF) shall be assessed face to face using the Uniform Assessment Instrument (UAI) in accordance with Assessment in Assisted Living Facilities. The UAI shall be completed at least annually. EVIDENCE: 1. The record for resident 3 has documentation that the last UAI review and update was completed on 8/25/2022. An interview was conducted with staff 1 on the day of inspection in which staff 1 verified that this was correct and that an annual review of resident 3?s UAI has not been completed.
Plan of Correction:	Administrator will ensure that all residents shall be assessed face Face using the uniformed assessment instrument annually or whenever There is a significant change in the resident's condition.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 3 has documentation that the last review and update of their ISP was completed on 8/26/2022. An interview was conducted with staff 1 on the day of inspection in which staff 1 verified that this was correct and that an annual update of resident 3?s ISP has not been completed.
Plan of Correction:	dministrator will ensure that all resident's individualized service Plan will be reviewed every 12 months and as needed.
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 3, 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 10/05/2023, staff 1 provided the documents ?Hourly Rounds Report? for resident 3 for the time period of 09/01/2023 through 09/30/2023. The report sheets did not include documentation that a round was made on resident 3 every hour on 09/29/2023 and 09/30/2023.
Plan of Correction:	Administrator will ensure that the care and services specified in the individualized service plan are adhered to. Logs wilt be reviewed. Complete A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.
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 September 2023 medication administration record (MAR) for resident 4 has documentation of a physician order dated 05/22/2022 for Prazosin 1mg, take one capsule at bedtime for nightmares, hold if SBP is less than 100. A form with resident 4?s name and documentation of ?Check B/P @ Bedtime? does not have documentation of the results of the residents blood pressure at bedtime on 09/28/2023 or 09/29/2023.
Plan of Correction:	Administrator will ensure that all medical procedures or treatment Ordered by a physician are adhered to. Logs will be reviewed Complete A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.
Standard #:	22VAC40-73-870-A
Description:	Based on observations 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 light fixture in the ceiling to the left in the resident sitting room was noted to be inoperable on the day of inspection.
Plan of Correction:	Administrator will ensure that the interior and exterior of facility will be Maintained in good repair. Facility will be inspected by staff for Needed repairs and cleanliness. Complete A plan of correction date was not provided for this violation. The date included in this notice is the date that the plan was received by the inspector.