A list of the most recent deficiencies for Ashford Hall. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-30 | 2023-12-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-01 | 2023-12-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2023-12-18 | Y |
| Post nurse staffing information every day. | Health | 2023-11-17 | 2023-11-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-20 | 2023-09-21 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-08-15 | 2023-09-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-15 | 2023-09-07 | Y |
| 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 | 2023-06-06 | 2023-06-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-04 | 2023-01-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-04 | 2023-01-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-14 | 2022-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-14 | 2022-10-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-09 | 2021-09-24 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-09-09 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-09-24 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-28 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-28 | 2021-08-17 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-28 | 2021-08-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-28 | 2021-08-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-28 | 2021-08-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-28 | 2021-08-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-02 | 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 | 2021-07-29 | 2021-08-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-28 | 2021-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-28 | 2021-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-07-29 | N |
