Deficiency Records for Ashford Hall
Updated as of March 01, 2022
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? |
---|---|---|---|---|
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 |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-11-27 | 2020-11-28 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-11-27 | 2020-11-28 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-05-15 | 2020-05-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-05-15 | 2020-05-16 | Y |
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 |
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 |
Provide and implement an infection prevention and control program. | 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 | Y |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-25 | 2019-11-22 | Y |
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 | Y |
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 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-11-08 | 2018-12-10 | 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 | 2018-11-08 | 2018-12-10 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-08 | 2018-12-10 | N |
Respond appropriately to all alleged violations. | Health | 2018-11-08 | 2018-12-10 | 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 | 2018-11-08 | 2018-12-10 | 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 | 2018-11-08 | 2018-12-10 | 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 | 2018-11-08 | 2018-12-10 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-08 | 2018-12-10 | N |
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 | N |
Provide and implement an infection prevention and control program. | Health | 2018-11-08 | 2018-12-10 | N |
Keep all essential equipment working safely. | Health | 2018-11-08 | 2018-12-10 | N |
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 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-11-08 | 2018-12-10 | N |