Deficiency Records for Ashford Hall
Updated as of February 01, 2020
This is not the most recent data for Ashford Hall. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-24 | 2019-11-28 | 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 | 2019-10-24 | 2019-11-28 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-24 | 2019-11-28 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-25 | 2019-11-22 | 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 | 2019-10-25 | 2019-11-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-25 | 2019-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-25 | 2019-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-25 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-11-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Develop a communication plan. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-11-08 | 2018-12-18 | 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 | 2018-11-08 | 2018-12-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-08 | 2018-12-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-08 | 2018-12-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-11-08 | 2018-12-10 | 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 | 2018-11-08 | 2018-12-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-08 | 2018-12-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-11-08 | 2018-12-10 | Y |
| 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 | 2018-11-08 | 2018-12-10 | Y |
| 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 | 2018-11-08 | 2018-12-10 | Y |
| 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 | 2018-11-08 | 2018-12-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-08 | 2018-12-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-08 | 2018-12-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-11-08 | 2018-12-10 | Y |
| Keep all essential equipment working safely. | Health | 2018-11-08 | 2018-12-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-08 | 2018-12-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-11-08 | 2018-12-10 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-24 | 2018-05-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-24 | 2018-05-18 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2018-04-24 | 2018-05-18 | Y |
| Keep all essential equipment working safely. | Health | 2018-03-08 | 2018-03-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-08 | 2018-03-28 | Y |
| Have policies on smoking. | Health | 2018-03-08 | 2018-03-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-11-01 | 2017-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-11-01 | 2017-11-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-01 | 2017-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-11-01 | 2017-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-11-01 | 2017-11-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-27 | 2017-11-15 | N |
| Keep all essential equipment working safely. | Health | 2017-07-25 | 2017-07-25 | Y |
