Deficiency Records for Ashford Hall
Updated as of June 01, 2023
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? |
---|---|---|---|---|
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 |
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 |
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 requirements for the installation and maintenance of electrical systems. | 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 |