The resident had completed a POLST form electing "do not attempt resuscitation" status. The form was kept in a binder at the nurses' station, and the resident's DNR order was transcribed on every page of their medication administration record.
But when an emergency occurred, none of that mattered.
Staff C, who was involved in the response, admitted inspectors that verification of the resident's code status "was not performed." When asked about checking physician orders in the resident's electronic health record, Staff C said: "Yes, we didn't get a chance to see that."
The Director of Nursing later confirmed what happened. "No it was not," Staff A said when inspectors asked if the resident's advance directive was honored during the emergency.
Staff A explained that the facility expected workers to verify a resident's code status using the POLST form during emergencies. But the form "was not available for the nurses to verify," she told inspectors.
The confusion points to a deeper problem at Ballard Center. Key staff members lacked current CPR certifications, raising questions about their preparedness for the very emergency they mishandled.
Staff E, a Licensed Practical Nurse, worked 23 days in one month and 24 days the following month according to staffing schedules. When inspectors interviewed Staff E, they discovered the nurse's CPR certification had lapsed.
"Now it's due," Staff E admitted.
The nurse said they had received CPR training from another workplace, but couldn't provide current certification from Ballard Center.
Staff F, a Certified Nursing Assistant who worked 20 days in one month, faced the same problem. The CNA told inspectors they were "scheduled to receive CPR training but that it was postponed."
When asked about their last CPR training, Staff F said it was "maybe years ago, and long time ago."
The facility's payroll administrator couldn't immediately produce the required certifications. Staff G and the Director of Nursing told inspectors they "would provide requested CPR certifications as able" during a follow-up interview.
The documents didn't surface until the next day.
At 6:24 PM, nearly 24 hours after inspectors first requested proof of training, Staff A finally provided CPR certifications for both workers. The certificates showed they had completed training on the same day inspectors asked for documentation.
The timing raised obvious questions about when the training actually occurred and whether the facility was scrambling to cover gaps in required certifications.
Staff A told inspectors that licensed staff were expected to complete required CPR training. But the evidence suggested the facility wasn't tracking compliance or ensuring workers maintained current certifications.
The emergency response failures extended beyond missing paperwork. Staff B, interviewed during a joint record review, confirmed that workers were supposed to check the master copy of completed POLST forms kept at each nurses' station.
Staff B also noted that residents' code status could be referenced through their electronic health record profile and physician orders. Multiple systems existed to verify a resident's wishes about resuscitation.
Yet somehow, during an actual emergency, none of these safeguards worked.
The resident's POLST form clearly showed they had elected DNAR status. Their physician orders included a DNR directive. The code status appeared on every page of their medication administration record, as Staff C acknowledged: "Every page on the MAR has the advance directives."
Staff C even told inspectors that "the expectation is to go by what the orders say."
But when it mattered most, those expectations collapsed.
The facility's Director of Nursing explained that advance directives, including POLST forms, were discussed with residents on admission. The process was designed to ensure residents' end-of-life wishes would be respected.
Instead, Ballard Center staff ignored a resident's explicit instructions about resuscitation while lacking the very training certifications that might have helped them respond appropriately to the emergency they mishandled.
The resident who elected not to be resuscitated received CPR anyway, delivered by staff whose certifications had lapsed years earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ballard Center from 2025-11-14 including all violations, facility responses, and corrective action plans.