Inspection Results » Ballard Center

Health Inspection on November 7, 2018 ^[1]

1. Isolated: Immediate jeopardy to the resident health or safety

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-12-20)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-12-20)

2. Pattern: Actual harm that is not immediate jeopardy

   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-12-20)

3. Isolated: Actual harm that is not immediate jeopardy

   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-12-20)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-12-20)
   • 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. (Corrected 2018-12-20)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-12-20)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-12-20)
   • 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. (Corrected 2018-12-20)

4. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-12-20)
   • Provide and implement an infection prevention and control program. (Corrected 2018-12-20)
   • 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. (Corrected 2018-12-20)
   • Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (Corrected 2018-12-20)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-12-20)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2018-12-20)

5. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Honor the resident's right to organize and participate in resident/family groups in the facility. (Corrected 2018-12-20)
   • 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 (Corrected 2018-12-20)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-12-20)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-12-20)

6. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-12-20)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-12-20)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2018-12-20)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-12-20)
   • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (Corrected 2018-12-20)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-12-20)
   • 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. (Corrected 2018-12-20)
   • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2018-12-20)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-12-20)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-12-20)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-12-20)
   • 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 ne (Corrected 2018-12-20)
   • 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. (Corrected 2018-12-20)