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: June 13, 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: 06/13/2023 8:15am 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: 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: 11 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 #:	22VAC40-73-150-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 06/13/2023 resulted in 15 violations of which 9 violations are repeat/systemic in nature in the areas of resident care and physical plant. This is a repeat violation from the 04/05/2023 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 June 2023 does not include the job classifications for the employees listed on the schedule. 2. The initials for staff 5 was observed on the June 2023 medication administration records for administering medications to residents for several days from 06/01/2023 through 06/13/2023. Interview with staff 4 expressed that staff 5 comes in certain days to administer AM and PM medications. Staff 5 name was not included on the June 2023 employee written schedule.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 06/13/2023, it was noted that resident 5 is still currently residing at the facility. This is a repeat violation from the 01/13/2023, 02/22/2023 and 04/05/2023 inspections.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that there was a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any, prior to the facility admitting an individual to the facility before a determination has been made that the facility can meet the needs of the individual. EVIDENCE: 1. Resident 10 was admitted to the facility on 04/25/2023. During on-site inspection, the record for the resident did not contain documentation of a documented interview that occurred between the administrator or a designee responsible for admission and retention decisions, the resident, and his legal representative, if any, prior to the facility admitting the resident. Interview with staff 4 confirmed that this was accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 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. This is a repeat violation from the 04/05/2023 inspection. 2. During on-site inspection, staff 4 brought into the facility a physical examination for resident 10, dated 04/12/2023, that she stated she had just picked up on this date from the doctor?s office because this physical examination had stated that the resident requires continuous licensed nursing care which is a prohibited condition for admission to an assisted living facility and she had taken it to be amended by the doctor?s office to be changed that the resident doesn?t require continuous licensed nursing care. The doctor?s office had whited out the section checked that yes the resident requires this condition/care need. The physical examination also stated that the resident is non-ambulatory and the facility is licensed for ambulatory residents only. 3. In addition, the record for resident 10 also contained a physical examination, dated 05/08/2023, that contains 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.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain prior to admission whether a resident is a registered sex offender. EVIDENCE: 1. Resident 10 was admitted to the facility on 04/25/2023. The Virginia State Police (VSP) sex offender registry search document in the record for the resident on day of inspection did not include the date that the search was conducted. This was also observed by staff 4.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-360-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that an emergency placement only occurred when the emergency was documented and approved by an adult protective services worker for public pay individuals or an independent physician or an adult protective services worker for private pay individuals. EVIDENCE: 1. The record for resident 10 contains a public pay uniform assessment instrument (UAI) completed by the local adult protective services with a screen date of 03/30/2023, an assessment date of 04/18/2023, and a reassessment date of 05/04/2023. The resident was admitted to the facility on 04/25/2023. 2. Interview with staff 4 revealed that the resident was an emergency placement by the local adult protective services agency; however, staff 4 revealed that she did not have documentation to provide to the licensing inspectors (LIs) during on-site inspection that was provided by the local adult protective services worker that documented the resident was an emergency placement admission to the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that all required personal and social information on a person was obtained prior to or at the time of admission to an assisted living facility. EVIDENCE: 1. The resident-personal/social data document in the record for resident 10 did not contain the following required information: birth date, interests/hobbies, lifetime vocation, career or primary role, clergyman/place of worship (if applicable), personal dentist, and the resident?s strengths.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 2 on 03/14/2023 at 8:15AM. The record for the resident did not contain documentation that the resident had attended this appointment. Staff 4 expressed during an interview that resident 9 refused to go to this appointment but the record for resident 9 does not have documentation of this refusal or documentation that the residents primary care physician was made aware of the resident not going to a scheduled medical appointment. This is a repeat violation from the 04/05/2023 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 June 2023 for resident 2 does not have the results of the residents blood sugar on 06/10/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on review of medication administration records (MARs), the facility failed to ensure that all required information was documented on resident MARs. EVIDENCE: 1. The June 2023 MAR for resident 1 does not have staff initials for the administration of the prescribed medication Buspirone Hcl 15mg at 12pm on 06/12/2023. 2. The June 2023 MAR for resident 2 does not have staff initials for the administration of the prescribed medication Glimepiride 1mg at 5pm on 06/12/2023. 3. The June 2023 MAR for resident 10 does not have staff initials for the administration of the prescribed medication Divalproex Sod ER 250mg at 3pm on 06/12/2023. 4. The June 2023 MAR for resident 11 does not have staff initials for the administration of the prescribed medication Benztropine 1mg at 3 pm on 06/12/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 06/13/2023, one licensing inspector (LI) measured the following hot water temperatures: the hot water tap in the men?s bathroom was recorded at 95 degrees Fahrenheit and the hot water tap in the women?s bathroom was recorded at 126.3 degrees Fahrenheit. This is a repeat violation from the 04/05/2023 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observations during a tour of the building, the facility failed to ensure cleaning supplies or other hazardous materials wrre stored in a locked area. EVIDENCE: 1. At approximately 10:02AM during on-site inspection, two licensing inspectors (LIs) and staff 4 observed a small, round peach colored pill imprinted with ?262? on the floor by the chair of the dining room table closest to the facility?s medication room. This pill was identified as Quetiapine Fumarate 25MG and during an interview with staff 1 it was revealed that resident 3 sits at this table during mealtimes. The record for resident 3 indicates that this resident is prescribed Quetiapine Fumarate 25MG daily at 8:00AM.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 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 and 04/05/2023 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 and 04/05/2023 inspections. 3. The doorknob on the door to room 5 was noted to be broken/inoperable on the day of inspection. This is a repeat violation from the 04/05/2023 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.