Ballard Center

In the surveyor’s words

From the most serious findings on record at Ballard Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF607Oct 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure systems were in place for staff following and implementing abuse and neglect policies & procedures for reporting, investigation, and protection for 16 of 16 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for abuse and neglect. These failures caused harm to Resident 1, 2, 3, 4, 5, 6 and 10 and placed other residents in the likelihood of serious harm and injury from abuse and neglect. […]

• Immediate jeopardy, patternF689Sep 13, 2022

  Based on interview and record review, the facility failed to provide adequate supervision and implement the care plan for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and supervision. Additionally, the facility failed to develop written policies and procedures related to the use of Motorized Wheelchairs (MW) and conduct a comprehensive assessment to ensure that residents were safe to operate a MW for 13 of 13 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14) reviewed for devices. These failures caused serious injury and serious harm to Resident 1 who sustained a [CONDITION(S)] and was hospitalized related to a MW incident with Resident 2. […]

• Immediate jeopardy, patternF689Feb 25, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision for both residents and staff when staff did not implement the care plans for 3 of 4 residents (Residents 1, 2 and 3) reviewed for avoidable accidents and falls. Failure to provide adequate supervision of staff as determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision as determined by the individual resident's assessed needs and identified hazards resulted in harm to Resident 1 and 2 and placed the other residents at risk for harm and injury. […]

• Immediate jeopardy, patternF689Sep 15, 2021

  Based on observation, interview and record review, the facility failed to develop and implement an effective policy and procedure(s) related to serving hot beverages, failed to provide adequate supervision, and failed to implement the plan of care for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and supervision. These failures caused serious harm and injury to Resident 1 who sustained a second-degree burn and experienced pain and placed other residents of the facility in the likelihood of serious harm and injury related to the unsafe temperature of hot beverages served. […]

• Actual harm, patternF600Feb 25, 2022

  Based on interview and record review, the facility failed to ensure residents were free from abuse or neglect for 8 of 10 residents (Residents 1, 4, 16, 3, 10, 11, 13 and 14) reviewed for abuse and neglect. This failure caused harm to Residents 1, 4, 16, 3, 10, 11, 13 and 14 and placed other residents at risk for harm and unmet care needs. Findings included . The Code of Federal Regulation (CFR) defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. RESIDENT 1 Resident 1 was a long-term resident of the facility. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]