Deficiency Records for Ballard Center
Updated as of July 01, 2023
This is not the most recent data for Ballard Center. For the most recent information, click here.
A list of the most recent deficiencies for Ballard Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-01 | 2022-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-16 | 2022-09-08 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-30 | 2022-08-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-30 | 2022-08-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-30 | 2022-08-31 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-07-30 | 2022-08-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-30 | 2022-08-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-30 | 2022-08-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-30 | 2022-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-30 | 2022-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-01 | 2022-08-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Meet other general requirements. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-01 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-04-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-25 | 2022-04-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-25 | 2022-04-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-25 | 2022-04-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-25 | 2022-04-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-25 | 2022-04-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-25 | 2022-04-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-25 | 2022-04-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-07 | 2021-11-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-07 | 2021-11-08 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-10-07 | 2021-11-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-07 | 2021-11-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-15 | 2021-11-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-15 | 2021-11-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-15 | 2021-11-08 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-09-15 | 2021-11-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-17 | 2021-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-17 | 2021-11-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-17 | 2021-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-12 | 2021-11-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-12 | 2021-11-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-17 | 2021-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-17 | 2021-09-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-17 | 2021-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-20 | 2021-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-10 | 2020-12-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-12-10 | 2020-12-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-11-03 | 2020-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-06 | 2020-12-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-10-06 | 2020-12-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-05 | 2020-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-06-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-05 | 2020-04-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-26 | 2020-04-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-26 | 2020-04-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-26 | 2020-04-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-26 | 2020-04-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-26 | 2020-04-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-26 | 2020-04-21 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-26 | 2020-04-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-26 | 2020-04-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-26 | 2020-04-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-26 | 2020-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-26 | 2020-04-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-26 | 2020-04-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-26 | 2020-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-26 | 2020-04-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-02-26 | 2020-04-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-26 | 2020-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-26 | 2020-04-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-02-26 | 2020-04-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-26 | 2020-04-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-05 | 2020-03-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-29 | 2019-01-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-07 | 2018-12-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-07 | 2018-12-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-11-07 | 2018-12-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-07 | 2018-12-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-07 | 2018-12-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-07 | 2018-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-11-07 | 2018-12-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-11-07 | 2018-12-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-07 | 2018-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-07 | 2018-12-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-11-07 | 2018-12-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-11-07 | 2018-12-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-07 | 2018-12-20 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-07 | 2018-12-20 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-11-07 | 2018-12-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-11-07 | 2018-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-07 | 2018-12-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-29 | 2018-11-30 | N |
