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: March 26, 2024

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: 03/26/2024 8:45am until 12:30pm 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 7 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 resident and staff record review, the facility administrator failed to demonstrate responsibility and general administration and management of the facility and oversee the day-to-day operation of the facility. EVIDENCE: 1. The current inspection conducted on 03/26/2024 resulted in 12 violations which include the areas of personnel, admission, retention and discharge, resident care and related services, building and grounds and emergency preparedness. 9 of the 12 violations cited are repeat/systemic in nature. This is a repeat violation from the 04/05/2023, 06/13/2023, 08/07/2023, 10/05/2023 and 01/30/2024 inspections.
Plan of Correction:	Administrator will continue in her training and gather knowledge from other Administrators to improve herself and get the skills necessary to oversee and manage the facility by: September 1, 2024
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interviews, the facility failed to ensure that at least one staff person who has certification in first aid was in the building at all times. EVIDENCE: 1. The record for staff person 6, hired on 12/02/2023 does not have documentation that this direct care employee has received certification in first aid. 2. The February 2024 employee work schedule has documentation that staff person 6 worked as the only employee in the building on the 11 to 7 shift on 02/01/2024, 02/02/2024, 02/03/2024, 02/04/2024,02/13/2024, 02/14/2024, 02/17/2024, 02/18/2024, 02/19/2024, 02/20/2024 and 02/26/2024. 3. The March 2024 employee work schedule has documentation that staff person 6 worked as the only employee in the building on the 7 to 11 shift on 03/08/2024 and on the 11 to 7 shift on 03/09/2024, 03/10/2024, 03/13/2024 and 03/14/2024. This is repeat violation from the 01/30/2024 inspection.
Plan of Correction:	Staff completed class and received certificate in First Aid on March 27, 2024
Standard #:	22VAC40-73-310-A
Description:	Based on resident record review, 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 and stipulations on the facility license indicate that all residents must be ambulatory. 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. A 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. An updated public pay UAI was completed on 10/26/2023 but does not indicate what level of care resident 3 is currently assessed at. The UAI does have documentation that resident 3 has a diagnosis of Alzheimer?s dementia, is dependent in 2 ADL?s, 8 IADL?s, medication management and is disoriented to some spheres all of the time. 5. A letter from the local Department of Social Services dated 11/28/2023 has documentation that regular assisted living accommodations are being sought for resident 3. 6. Physical examinations dated 12/21/2020 and 09/15/2023 both have documentation that resident 3 is non-ambulatory and requires continuous licensed nursing care. 7. During an on-site inspection conducted on 03/26/2024, 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, 08/07/2023, 10/05/2023 and 01/30/2024 inspections.
Plan of Correction:	Since the March 26, 2024, inspection there have been two facilities that have met Resident#3 for possible placement. Resident #3 remains at the Banister facility. Resident #3 was discharged from the facility on 04/17/2024.
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 and a subsequent physical examination dated 09/15/2023. Both examinations have documentation that the resident has 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, 08/07/2023, 10/05/2023 and 01/30/2024 inspections.
Plan of Correction:	BRCF continues to provide Resident #3 with a Personal Care Aide to ensure his safety, health and personal care.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review the facility failed to ensure that individualized service plans (ISP) were reviewed and updated at least annually. EVIDENCE: 1. The ISP in the record for resident 4 has documentation that the last review/update was completed on 02/09/2022. In an interview conducted with staff person 1 on 03/26/2024, staff person 1 expressed that this was correct.
Plan of Correction:	A New ISP update was completed on April 9, 2024, for resident #4.
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 11/10/2023, included an identified need that the resident has memory loss, and that direct care staff will monitor the resident every hour during the day and evening for safety. 2. During on-site inspection on 03/26/2024, staff 1 provided the documents ?Hourly Rounds Inspection Report? for resident 3 for 02/01/2024 through 03/26/2024. The report sheets did not include documentation that a round was made on resident 3 every hour on 02/23/2024, 02/26/2024, 02/27/2024, 02/29/2024 and 03/16/2024. This is a repeat violation from the 10/05/2023 and 01/30/2024 inspections.
Plan of Correction:	The Administrator will review the Hourly Rounds Inspection Report for Resident #3 daily that rounds are made hourly every day. Beginning 04/01/2024. Resident #3 was discharged on 04/17/2024.
Standard #:	22VAC40-73-550-G
Description:	Based on resident and staff record review, the facility failed to ensure that a review of resident rights was completed annually with residents and staff. EVIDENCE: 1. The record for resident 2 has documentation that the last review of resident rights was completed on 11/29/2022. 2. The record for resident 3 has documentation that the last review of resident rights was completed on 04/16/2022. This is a repeat violation from the 01/30/2024 inspection.
Plan of Correction:	Administrator reviewed Rights and Responsibilities on April 8, 2024
Standard #:	22VAC40-73-670-3
Description:	Based on staff record review and staff interview, the facility failed to ensure that the administrator who provides supervision of medication aides has completed training/educational requirements. EVIDENCE: 1. The record for staff person 1, the facility administrator, hired on 10/02/2023, does not have documentation that they have completed a 68-hour medication training program approved by the Virginia Board of Nursing. In an interview with staff person 1 on 03/26/2024, staff person 1 expressed that they have not completed this class yet. The LI noted that the facility does not employ any individuals on a full-time basis who are licensed by the Commonwealth of Virginia to administer medications. This is a repeat violation from the 01/30/2024 inspection.
Plan of Correction:	Certification of completion was received on March 28, 2024
Standard #:	22VAC40-73-680-I
Description:	Based on review of resident medication administration records (MARs), the facility failed to ensure that all required information was documented on resident MARs. EVIDENCE: 1. The March 2024 MAR for resident 2 has a physician order for Vitamin D2 1.25mg/50,000, take one capsule by mouth once weekly on Tuesdays for Vit Def. The March MAR has documentation of staff initials that are marked through on 03/01/2024, 03/02/2024, 03/03/2024, 03/05/2024 and 03/06/2024 but there is no documentation as to why they are marked through or if the medication was or was not administered on these days. 2. The March 2024 MAR for resident 5 has a physician order for propranolol 10mg, take 1 tablet by mouth twice daily as needed for restlessness. Staff initials are present on 03/11/2024 for the administration of this medication but there is no documentation of the effectiveness of the medication. 3. The March 2024 MAR for resident 6 has a physician order for Acetaminophen Er 650mg, take 1 tablet by mouth 3 times a day (every 8 hours) as needed for generalized joint pain. Staff initials are present for the administration of this medication twice daily on 03/04/2024, 03/05/2024 and 03/08/2024 but there is only documentation of the effectiveness of the medication for one of the administered doses for each of these days.
Plan of Correction:	Althea Price RN, BSN discussed these violations with the RMAs on staff on March 28, 2024, so this will not occur in the future. Administrator was present.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair. EVIDENCE: 1. The hallway outside of room 6 was noted to have a ceiling access door to the attic. The trim around the access door was observed to be loose/hanging from the ceiling and the access door was observed to have a crack.
Plan of Correction:	The maintenance department repaired the attic assess door on March 26, 2024.
Standard #:	22VAC40-73-950-A
Description:	Based on review of facility documentation, the facility failed to ensure that contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency was completed annually and documented. EVIDENCE: 1. The LI requested to review the facility documentation of annual contact with the local emergency coordinator that determines local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency. In an interview with staff 1 on 03/26/2024, staff 1 expressed that there is no documentation of contact with the local emergency coordinator. This is a repeat violation from the 01/30/2024 inspection.
Plan of Correction:	Letter dated March 11, 2024, was received from Jason Johnson the Emergency Services Coordinator of Halifax County concerning his March 8, 2024, visit to review BRCF Emergency Preparedness Plan
Standard #:	22VAC40-73-950-E
Description:	Based on resident record and facility documentation review and staff interviews, the facility failed to ensure that a semi-annual review of the facility emergency preparedness plan was completed with all residents. EVIDENCE: 1. The LI requested to review documentation of a semi-annual review of the facility emergency preparedness plan with all residents on 03/26/2024, the day of inspection. In an interview with staff 1 conducted on 03/26/2024, staff 1 expressed that there is not documentation of a semi-annual review of the facility emergency preparedness plan with residents. This is a repeat violation from the 01/30/2024 inspection.
Plan of Correction:	Administrator completed a semi- annual review with residents of BRCF emergency preparedness plan on April 9,2024