Banister Residential Care Facility, Inc.
1017 Bethel Road
Halifax, VA 24558
(434) 476-8811
Current Inspector: Cynthia Jo Ball (540) 309-2968
Inspection Date: Jan. 25, 2022 and Jan. 28, 2022
Complaint Related: No
- Areas Reviewed:
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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 ACCOMODATIONS AND RELATED PROVISIONS
22VAC40-73 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS
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:
-
On 1/25/2022 two licensing inspectors conducted an onsite renewal study from 8:15 am to 12:35 pm. 11 residents were in care. Three resident records, one volunteer record, and three staff records were fully reviewed. Two resident records were partially reviewed. A medication pass was observed and a resident was interviewed. A preliminary exit meeting was done on site on the day of the inspection, and a formal exit was conducted over the phone on 2/7/2022; an opportunity was given to provide evidence to show that some items were cited incorrectly.
- Violations:
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Standard #: 22VAC40-73-100-A Description: Based on document review, the facility failed to have documentation that a licensed health care professional, practicing within the scope of his profession and with training in infection prevention, was included in the annual review of the facility infection control plan. Documentation of this is required to be maintained at the facility.
EVIDENCE:
1. There is no documentation to support that a licensed health care professional participated in the annual review of the facility infection control plan.Plan of Correction: Administrator will show documentation indicating a license health care professional is practicing within the scope of his profession [sic]. Documentation will be provided in employee folder for viewing [sic]
Standard #: 22VAC40-73-100-C-2 Description: Based on document review, the facility failed to include required sections in their written infection control plan.
EVIDENCE:
1. The facility's written infection control plan does not include: the required plan for how the facility will determine if returning or prospective residents have acute infectious disease and how to prevent disease transmission; the handling, storing, and transporting of linens, supplies, and equipment in a manner that prevents the spread of infection; and the handling, storing, processing, and transporting of medical waste in accordance with applicable regulations.Plan of Correction: The administrator and health oversite nurse will update the infection control policy. Staff will review and sign off acknowledging tht they have read the updated infection control policy. The updated policy will reflect on the written violation.
Standard #: 22VAC40-73-240-C Description: Based on volunteer record review, the facility failed to maintain required documentation on volunteers.
EVIDENCE:
1. The volunteer record for volunteer 1 lacks: address, telephone number, emergency contact information, information on any qualifications, orientation, training, and education required, including any specific relevant information.Plan of Correction: Administrator will ensure the volunteer record review will be done and documented before start date..
Standard #: 22VAC40-73-260-A Description: Based on staff record review, the facility failed to ensure that new direct care staff had certification of First Aid training within 60 days of hire.
EVIDENCE:
1. Staff 1 began work on 11/12/2021. The record for staff 1 has no documentation to support that First Aid training had been done. This was noted on 1/25/2022.
2. Staff 3 began work on 10/26/2021. The record for staff 3 has no documentation to support that First Aid training had been done. This was noted on 1/25/2022.Plan of Correction: Administrator will ensure that new direct care staff will have first aid and CPR completed on or 60 days of hire date [sic].
Standard #: 22VAC40-73-260-C Description: Based on observation, interview, and staff record review, the facility failed to have a posted list of staff with current certification in First Aid and CPR kept up to date.
EVIDENCE:
1. The posted first aid and CPR list showed that staff 2 did not have certification in first aid or CPR. Interview with staff 2 confirms that she has had this training. The record for staff 2 shows she is currently certified in first aid and CPR.Plan of Correction: Administrator will post a current staff list indicating certification if First Aid and CPR and ensure that information is up to date.
Standard #: 22VAC40-73-290-A Description: Based on document review, the written work schedule lacked some required elements.
EVIDENCE:
1. The undated written work schedule covering the period from Monday through Sunday given to the LI by the administrator lacked: job classifications, and an indication of whomever is in charge at any given time.Plan of Correction: Administrator will post monthly work schedules indicating who is in charge and staff job classification. Administrator will ensure that the correct date is posted daily.
Standard #: 22VAC40-73-290-B Description: The facility failed to have posted the name of the current on-site person in charge.
EVIDENCE:
1. On 1/25/2022 the "in charge" posting showed who was in charge on 1/23/2022.Plan of Correction: Administrator will ensure that the correct date is posted daily of staff working and who is in charge daily. [sic]
Standard #: 22VAC40-73-310-D Description: Based on a review of resident records, the facility failed to insure that written assurance that the facility has the appropriate license to meet their care needs was provided to residents.
EVIDENCE:
1. The record for resident 1, admitted on 03/15/2021 did not have documentation that based on a review of the residents uniform assessment instrument, the administrator provided written assurance to the resident at the time of admission that the determination was made that facility has the appropriate license to meet the residents care needs.Plan of Correction: Administrator will ensure that during admission the written assurance will indicate that Banister has the appropriate license to meet their care needs.
Standard #: 22VAC40-73-320-A Description: Based on resident record review, the facility failed to ensure that a physical exam done within 30 days prior to admission addressed some required components.
EVIDENCE:
1. The physical exam done within 30 days prior to admission for resident 1 showed the resident is allergic to penicillin and there was no description or mention of the resident's reactions. The same physical was also missing a statement that Resident 1 does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H, a statement that specifies whether resident 1 is considered to be ambulatory or non-ambulatory, a statement that specifies whether resident 1 is or is not capable of self-administering medication, and the form lacks the signature of the examining physician or designee.
2. Evidence #1 was cited on 10/25/2021, and as of 1/25/2022 the missing information and physician's signature for resident 1 has not been obtained.Plan of Correction: Administrator will ensure that during admissions a physical exam will be done within 30 days of employment [sic]. Model form will be used to ensure that all required components are addressed.
Administrator will ensure that allergies are documented on physicals indicating the allergies and reactions.
Standard #: 22VAC40-73-380-A Description: Based on a review of resident records, the facility failed to ensure that all required personal and social data was obtained.
EVIDENCE:
1. The personal/social data form in the record for resident 1 did not contain documentation of the residents lifetime vocation, career or primary role or information of services in Armed Forces if applicable.Plan of Correction: Administrator will ensure that personal and social data are obtained during admission and completed with out any empty sections.
Standard #: 22VAC40-73-410-A Description: Based on a review of resident records, the facility failed to provide an orientation to the facility for new residents.
EVIDENCE:
1. The record for resident 1, admitted on 03/15/2021, did not contain documentation that the resident signed for acknowledgement of receiving an orientation to the facility at the time of admission.Plan of Correction: Administrator will ensure that during admission the resident will be provided with an orientation to the facility for new residents.
Standard #: 22VAC40-73-440-A Description: Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed at least annually or when a significant change in a residents condition occurred.
EVIDENCE:
1. The UAI dated 02/03/2021 in the record for resident 1 has documentation that the resident self-administers their medications but it was observed that the resident is receiving medication administration services from the facility.
2. The record for resident 2 has documentation that the last UAI assessment for this resident was completed on 12/04/2020. This was noted on 1/25/2022.Plan of Correction: Administrator will ensure UAI'S [sic] are documented according to resident's needs. Corrections should be addressed to the individual that did the UAI and then document findings that was [sic] incorrect should be placed in resident file.
Standard #: 22VAC40-73-450-F Description: Based on a review of resident records, the facility failed to ensure that individualized service plans (ISPs) were reviewed and updated at least every 12 months and as needed as the condition of a resident changes.
EVIDENCE:
1. The uniform assessment instrument (UAI) dated 02/03/2021 in the record for resident 1 has documentation that the resident is incontinent of bowel less than weekly and that they require mechanical assistance for walking, stairclimbing and mobility. The ISP reviewed on 05/13/2021 does not address these identified needs.
2. The record for resident 3 has documentation of a physician order dated 12/28/2021 for a no added salt and no concentrated sweet diet. The ISP dated 07/30/2021 in the record for resident 3 does address this identified need.
3. The UAI dated 4/21/2021 in the record for resident 4 shows this resident needs mechanical help only when bathing. The ISP dated 5/10/2021 shows that supervision is given instead.Plan of Correction: Administrator and [sic] will ensure that ISP'S [sic] are updated at least every 12 months and as needed.
Standard #: 22VAC40-73-490-B Description: Based on document review, the facility failed to obtain an on-site health care oversight with all of the required information.
EVIDENCE:
1. The Health Care Oversight document dated 7/21/2021 lacks documentation showing: monitoring direct care staff performance of health-related activities, evaluating the need for staff training, monitoring conformance to the facility's medication management plan and the maintenance of required medication reference materials, evaluation of the ability of residents who self-administer medications to continue to safely do so, and observing infection control measures and consistency with the infection control program of the facility.Plan of Correction: Administrator will ensure that on-site-health care has all required information. Model form will be used to address all required components.
Standard #: 22VAC40-73-550-G Description: Based on a review of resident records, the facility failed to ensure that a review of resident rights and responsibilities was completed annually with all residents and staff.
EVIDENCE:
1. The record for resident 2, admitted on 12/16/2016, has documentation that the last annual review of resident rights and responsibilities was completed on 07/02/2020. This was noted on 1/25/2022.
2. The record for staff 4 lacks documentation that reviews of resident rights and responsibilities have been done.Plan of Correction: Administrator will ensure that Resident rights [sic] and Responsibilities are completed annually with with resident's [sic] and staff.
Standard #: 22VAC40-73-610-B Description: Based on observation, the facility failed to post the menu for meals and snacks for the current week.
EVIDENCE:
1. The menu posted wall of the dining area that is an extension of hallway was dated 1/16/2022 to 1/22/2022. This was noted on 1/25/2022.Plan of Correction: Administrator will ensure that the menu for meals and snacks are [sic] posted weekly with current dates for the week.
Standard #: 22VAC40-73-610-D Description: Based on a review of resident records, observations of the facility kitchen and interviews with staff, the facility failed to ensure that special diets were prepared and served according to physicians orders.
EVIDENCE:
1. The record for resident 3 has documentation of a physician order dated 12/28/2021 for the resident to have a no added salt and no concentrated sweets diet. The LI observed that there were no special diets listed in the facility kitchen for dietary staff to be aware of residents that have been prescribed special diets. Interviews were conducted with staff person 2, who was preparing lunch in the facility on the day of inspection, and staff person 4, who was administering medications in the facility. Both staff persons expressed that they were not aware of any residents currently residing in the facility that had a prescribed special diet.Plan of Correction: Administrator will ensure residents diets are posted on index cards and made available for staff to review when preparing meals.
Standard #: 22VAC40-73-650-A Description: Based on resident record review, the facility failed to have an order to change a medication.
EVIDENCE:
1. The medication administration record shows that resident 5 is given Metformin HEL [sic] 500 mg one tablet by mouth with evening meal. The record for resident 5 has an order for Metformin 500 mg one half tablet by mouthy with the morning and evening meal.Plan of Correction: Administrator will ensure all new orders will be placed in residents file indicating a change in medication.
Standard #: 22VAC40-73-680-E Description: Based on a review of resident records, the facility failed to ensure that all medical procedures or treatments were documented in the resident records.
EVIDENCE:
1. The record for resident 1 has a physician order dated 08/18/2021 for oxygen 3 liter a minute via nasal cannula for nocturnal use with concentrator. The January 2022 medication administration record (MAR) for resident 1 does not have documentation of the oxygen use.
2. The record for resident 2 has a physician order dated 01/19/2022 for blood pressure checks daily for one week and send reading to the heart center. The January 2022 MAR for resident 2 does not have documentation of the results of resident 2?s blood pressure check on 01/22/2022 or 01/23/2022.Plan of Correction: Administrator will ensure all medical procedures or treatments are documented on the resident MAR.
Standard #: 22VAC40-73-860-I Description: Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
EVIDENCE:
1. A can of bug spray was on the TV shelf in the dining room.
2. The laundry room was unlocked and had the following on a shelf: detergent, cleaner with bleach, bottle of indoor/outdoor pest control, sanitizer, and carpet cleaner.Plan of Correction: Administrator will ensure cleaning supplies and hazardous materials are locked in closet.
Standard #: 22VAC40-73-870-A Description: Based on observation, the facility failed to maintain the interior and exterior of the building in good repair and kept clean and free of rubbish.
EVIDENCE:
1. In room 8 the ceiling access panel is damaged.
2. The unisex bathroom had brown dirt buildup on the edges of the floor near the walls.
3. The unisex bathroom had holes in the wall below and to the the left of the light switch.
4. The floor near the toilet in the unisex bathroom had dried brown lumps and smears on it.
5. The floor near the toilet in the unisex bathroom had damaged floor tiles, and they were missing in some sections.
6. The men's bathroom had a loose bracket attached to the wall.
7. The men's bathroom had a heavy brown build up of dirt on the edges and corners of the floor.
8. The men's bathroom had damaged floor tile near the toilet, coming loose and not fully covering the floor.
9. The men's bathroom had damaged floor molding near the sink. A piece was missing and appeared to have been heavily water damaged.
9. The door jam to the laundry room was missing a large chunk and a nail was now sticking out where the wood was torn away.
10. There was a heavy build up of tan/brown dirt or dust outside the hall door to room 5.
11. The entry door had black/brown smudges near the doorknob, both inside and out.
12. The ceiling of the women's rest room had water damage.
13. The bedroom hallway has a loose receptacle plate.
14. The floor near the French doors in the living room had damaged flooring and there is a bumpy, uneven, grey substance there.
15. The closet door in room 5 was inoperable. It was off the tracks, and the floor under it was damaged.
16. The wall in the hallway between rooms 3 and 4 had holes in it.
17. The baseboard near the women's rest room to the right of the door was coming loose and sticks out.
18. The side of the building has brownish-green discoloration in the area above the propane tank.Plan of Correction: Administrator will ensure interior and exterior of building are in good repair and free of rubbish daily. Concerns will be addressed immediately. Proper plan of care will be documented and repairs will be done accordingly.
Standard #: 22VAC40-73-870-E Description: Based on observation, the facility failed to keep furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, clean and in good repair and condition.
EVIDENCE:
1. The toilet in the unisex bathroom had brown stains inside the bowl.
2. The ceiling light cover in the toilet area of the unisex bathroom had brown objects visible inside it.
3. There was an inoperable light in the unisex bathroom.
4. The men's bathroom had a dark substance around the faucet and the bowl of the sink where it joined the countertop.
5. The men's bathroom had either a stain or soil on the outside of the toilet. It was dark brownish-yellow.
6. The men's bathroom had bugs inside the toilet room light and the ceiling vent had a heavy dust build up.
7. A chair in the kitchen has stains on the upholstery of the seat.Plan of Correction: Administrator will assign rooms to staff daily for cleaning and documentation will be kept in front office for viewing. Maintenance slips will be available for staff, slips will be place in folder on wall in front office and pulled daily. Once work order is completed, completed orders will be placed in a separate folder.
Administrator will ensure that lights throughout the building are replaced as need [sic] to ensure proper lighting. Bathrooms will be assigned to staff for cleanliness and signed off, [sic] when completed.
Standard #: 22VAC40-73-920-C Description: Based on observation, the facility failed to provide ventilation to the outside in toilet areas.
EVIDENCE:
1. The fan in the toilet room of the unisex bathroom is inoperable, thus not providing ventilation.Plan of Correction: Administrator will ensure that ventilations fans are placed in bathrooms for outside ventilation.
Standard #: 22VAC40-73-925-B Description: Based on observation, the facility failed to provide soap at a handwashing sink.
EVIDENCE:
1. The common unisex bathroom had no liquid soap.Plan of Correction: Administrator will ensure soap dispensers are attached to walls for use and checked daily to ensure soap is in dispenser. Banister will supply liquid soap instead of bar soap for resident use.
Standard #: 22VAC40-73-925-C Description: Based on observation, the facility failed to ensure that residents would not share bar soap.
EVIDENCE:
1. The men's common bathroom had only bar soap.Plan of Correction: Administrator will ensure that bar soap will be replaced with liquid soap for resident's use.
Standard #: 22VAC40-73-950-E Description: Based on lack of documentation and staff interview, the facility failed to have semi-annual reviews of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review is required to be documented by signing and dating.
EVIDENCE:
1. There was no documentation to support that a semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers was completed. Staff 5 confirmed, in an interview, that the review had not been done.Plan of Correction: Administrator will ensure documentation of semi-annual reviews are done for emergency preparedness and response plan for staff, residents, and volunteers implementing [sic] on an individual's responsibilities.
Standard #: 22VAC40-73-960-B Description: Based on observation, the facility failed to have a posted evacuation drawing that showed primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers.
EVIDENCE:
1. The fire and emergency evacuation drawing posted in the resident bedroom hallway did not show the primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers.Plan of Correction: Administrator will ensure that the fire and emergency evacuation drawings are posted with primary and secondary escape routes.
Standard #: 22VAC40-73-990-C Description: Based on lack of documentation and staff interview, the facility failed to conduct, at least once every six months, an exercise in which the procedures for resident emergency are practiced with all staff on duty on each shift. Documentation of this is required to be maintained in the facility for at least two years.
EVIDENCE:
1. There was no documentation to support that the practice exercise had been done within the past six months. In an interview, staff 5 conformed it had not been done.Plan of Correction: Administrator will ensure that procedures for resident's emergency are practiced with all staff on duty each shift.
Standard #: 22VAC40-90-40-B Description: Based on staff record review, the facility failed to obtain a Virginia State Police Criminal History Record report on new staff on or prior to the 30th day of employee for an employee.
EVIDENCE:
1. The record for staff 2, who began work in the facility on 10/25/2021, lacks the results of a Virginia State Police Criminal History Record report. This was noted on 1/25/2022.Plan of Correction: Administrator will ensure new staff will obtain a Virginia State Police Criminal History Report on or prior to 30 days of employment.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.