Ashford Hall

Penalties

• Mar 4, 2026 — Fine ($15,935)
• Sep 24, 2024 — Fine ($6,144)
• Aug 10, 2024 — Fine ($22,391)
• Mar 22, 2024 — Fine ($256,785)

Inspection findings

1. Apr 9, 2026 Health · 10 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Apr 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected May 1, 2026 · CMS fire safety

2. Mar 24, 2026 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Mar 25, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 25, 2026 · CMS health inspection

3. Mar 4, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Mar 5, 2026 · CMS health inspection

4. Dec 17, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Dec 19, 2025 · CMS health inspection

5. Jan 24, 2025 Fire Safety · 21 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0023 Emergency Preparedness Deficiencies

     Establish policies and procedures for medical documentation.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0030 Emergency Preparedness Deficiencies

     List the names and contact information of those in the facility.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0325 Smoke Deficiencies

     Have properly installed hallway dispensers for alcohol-based hand rub.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0917 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure electrical receptacles or cover plates have distinctive color or marking.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Feb 3, 2025 · CMS fire safety

6. Jan 13, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jan 22, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0603 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

     Corrected Jan 22, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jan 22, 2025 · CMS health inspection

7. Sep 24, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0622 Resident Rights Deficiencies

     Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

     Corrected Sep 27, 2024 · CMS health inspection

8. Aug 10, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Aug 11, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 11, 2024 · CMS health inspection

9. Jul 2, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 3, 2024 · CMS health inspection

10. Apr 17, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0660 Resident Assessment and Care Planning Deficiencies

      Plan the resident's discharge to meet the resident's goals and needs.

      Corrected Apr 18, 2024 · CMS health inspection

11. Apr 4, 2024 Health · 2 findings
    • Serious Scope/severity K Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Apr 5, 2024 · CMS health inspection

    • Serious Scope/severity K Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 5, 2024 · CMS health inspection

12. Mar 22, 2024 Health · 2 findings
    • Serious Scope/severity K Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Mar 23, 2024 · CMS health inspection

    • Serious Scope/severity K Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Mar 23, 2024 · CMS health inspection

13. Dec 1, 2023 Health · 10 findings
    • Not serious Scope/severity E Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Dec 18, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Dec 18, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0211 Egress Deficiencies

      Keep aisles, corridors, and exits free of obstruction in case of emergency.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0325 Smoke Deficiencies

      Have properly installed hallway dispensers for alcohol-based hand rub.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Dec 22, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Dec 22, 2023 · CMS fire safety

14. Nov 17, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Nov 18, 2023 · CMS health inspection

15. Sep 20, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Sep 21, 2023 · CMS health inspection

16. Aug 15, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0640 Resident Assessment and Care Planning Deficiencies

      Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

      Corrected Sep 7, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Sep 7, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BARRIENTOS, BRENDA — adp of the snf, NOT APPLICABLE, since 10/09/2017
• BARRIENTOS, BRENDA — operational/managerial control, NOT APPLICABLE, since 10/09/2017
• BENENATE, JOSEPH — adp of the snf, NOT APPLICABLE, since 01/03/2000
• JENSEN, CHRISTIAN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/11/2025
• LEE, CHRISTOPHER — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/04/2025
• LEE, DARREN — adp of the snf, NOT APPLICABLE, since 09/01/2019
• LEE, DARREN — corporate director, NOT APPLICABLE, since 09/01/2019
• LEE, DARREN — corporate officer, NOT APPLICABLE, since 09/01/2019
• LEE, DARREN — 5% or greater indirect ownership interest, since 09/01/2019
• LEE, MICHAEL — 5% or greater indirect ownership interest, since 09/01/2019
• LEE, MIRIAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/04/2025
• LEE, NATHAN — corporate director, NOT APPLICABLE, since 09/01/2019
• LEE, NATHAN — corporate officer, NOT APPLICABLE, since 09/01/2019
• LEE, NATHAN — adp of the snf, NOT APPLICABLE, since 09/01/2019
• LEE, NATHAN — operational/managerial control, NOT APPLICABLE, since 09/01/2019
• MOFFITT, ROZINA — adp of the snf, NOT APPLICABLE, since 03/03/2025
• OLLILA, PATRICK — corporate director, NOT APPLICABLE, since 09/01/2019
• SORRELL, ANNA — corporate officer, NOT APPLICABLE, since 03/14/2014
• CAMAS INVESTMENT TRUST — 5% or greater indirect ownership interest, since 08/23/2007
• FORVIS MAZARS LLP — adp of the snf, NOT APPLICABLE, since 02/01/2016
• KARAN ASSOCIATES TWO, LLC — adp of the snf, NOT APPLICABLE, since 02/15/1994
• LEHI INVESTMENTS TRUST — 5% or greater indirect ownership interest, since 08/23/2007
• LION GROUP OF COMPANIES, INC — 5% or greater indirect ownership interest, since 05/01/2000
• LION HEALTH CENTERS, INC. — 5% or greater direct ownership interest, 100%, since 09/01/2019
• LION HEALTH CENTERS, INC. — adp of the snf, NOT APPLICABLE, since 04/11/2025
• NUTRITIOUS LIFESTYLES, INC. — adp of the snf, NOT APPLICABLE, since 01/20/2020
• PHARMACY CORPORATION OF AMERICA — adp of the snf, NOT APPLICABLE, since 09/29/2015
• PREFERRED PROPERTY INVESTMENTS, LLC — 5% or greater indirect ownership interest, since 12/01/1995