F
37/100Ashford Hall Inspection Report, Violations & Safety Grade (Irving, Texas)
2021 Shoaf Dr, Irving, Texas 75061
Phone: 9725791919
CMS Overall:1/5
Overview & Bed Count
Certified Beds
206
Avg Residents/Day
110.7
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Dallas
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.94 | 0.44 | +0.50 |
| Total Nurse Hours per Resident per Day | 3.99 | 3.42 | +0.58 |
| CMS Staffing Rating | 3/5 | 1.9/5 | - |
| Nursing Staff Turnover | 78.2% | 50.8% | - |
Health Citation History
32 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2026-04-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-04-09 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2026-04-09 | 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. | D – Moderate Harm Potential |
| 2026-04-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-03-24 | 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. | G – Actual Harm |
| 2026-03-24 | 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. | E – Moderate Harm Potential |
| 2026-03-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-12-17 | 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. | E – Moderate Harm Potential |
| 2025-01-24 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2025-01-24 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2025-01-24 | Quality of Life and Care Deficiencies | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2025-01-24 | 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. | D – Moderate Harm Potential |
| 2025-01-13 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2025-01-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | D – Moderate Harm Potential |
| 2025-01-13 | 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. | D – Moderate Harm Potential |
| 2024-09-24 | 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. | D – Moderate Harm Potential |
| 2024-08-10 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-08-10 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2024-07-02 | 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. | D – Moderate Harm Potential |
| 2024-07-02 | 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. | D – Moderate Harm Potential |
| 2024-07-02 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-04-17 | Resident Assessment and Care Planning Deficiencies | Plan the resident's discharge to meet the resident's goals and needs. | D – Moderate Harm Potential |
| 2024-04-04 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-04-04 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2024-03-22 | 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. | K – Immediate Jeopardy |
| 2024-03-22 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | K – Immediate Jeopardy |
| 2023-12-01 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2023-12-01 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2023-11-17 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | D – Moderate Harm Potential |
Fire Safety Citation History
28 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-09 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2026-04-09 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2026-04-09 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2026-04-09 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2026-04-09 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2025-01-24 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-01-24 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | F – Moderate Harm Potential |
| 2025-01-24 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | F – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | F – Moderate Harm Potential |
| 2025-01-24 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure electrical receptacles or cover plates have distinctive color or marking. | E – Moderate Harm Potential |
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Have properly installed hallway dispensers for alcohol-based hand rub. | D – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-01-24 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Have properly installed hallway dispensers for alcohol-based hand rub. | E – Moderate Harm Potential |
| 2023-12-01 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
| 2023-12-01 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2023-12-01 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
Total Penalties & Fines
$295,678
Total Fine Amount (CMS)
4
Number of Fines
4
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-03-04 | Fine | $10,358 | - |
| 2024-09-24 | Fine | $6,144 | - |
| 2024-08-10 | Fine | $22,391 | - |
| 2024-03-22 | Fine | $256,785 | - |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Irving area at no cost.
Find Safe, Vetted Facilities Near Irving
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.