01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-09 | 9 | 2026-04-09 | 5 |
| Cycle 2 | 2025-01-24 | 12 | 2025-01-24 | 15 |
| Cycle 3 | 2023-12-01 | 14 | 2023-12-01 | 8 |
CMS CCN 4557482026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Ashford Hall
2021 Shoaf Dr · Irving, TX 75061 · Dallas County
Certified beds206CMS provider file
Recent citation rows63current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
63 rows in the current release
6 rows carry G–L scope/severity codes; 5 carry J–L. 13 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-09 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-09 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-09 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-09 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-09 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-09 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-09 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-04-09 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-04-09 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-04-302026-04-09 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2026-05-012026-03-24 · HEALTHF0600Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2026-03-25 · complaint2026-03-24 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-03-25 · complaint2026-03-04 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2026-03-05 · complaint2025-12-17 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-01-24 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · FIREE0023Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for medical documentation.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · FIREE0030Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0691Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-032025-01-24 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-02-0303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-03-04 | Fine | $15,935 | 0 |
| 2024-09-24 | Fine | $6,144 | 0 |
| 2024-08-10 | Fine | $22,391 | 0 |
| 2024-03-22 | Fine | $256,785 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LION HEALTH CENTERS, INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 09/01/2019
- CAMAS INVESTMENT TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 08/23/2007
- LEHI INVESTMENTS TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 08/23/2007
- LION GROUP OF COMPANIES, INCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 05/01/2000
- PREFERRED PROPERTY INVESTMENTS, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/01/1995
- LEE, DARRENIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 09/01/2019
- LEE, MICHAELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 09/01/2019
- LEE, DARRENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2019
- LEE, NATHANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2019
- OLLILA, PATRICKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2019
- LEE, DARRENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2019
- LEE, NATHANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/01/2019
- SORRELL, ANNAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/14/2014
- BARRIENTOS, BRENDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/09/2017
- LEE, NATHANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2019
- JENSEN, CHRISTIANIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
- LEE, CHRISTOPHERIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/04/2025
- LEE, MIRIAMIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 04/04/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.71per resident day
RN hours0.88per resident day
Weekend nurse hours3.42per resident day
Staff turnover77.1%CMS reported field
06 / LOCAL RECORDS
Open the Irving ledger →Other published facilities nearby
Avante Rehabilitation Center120 beds · CMS overall 2/523 citation rowsAvir At Irving84 beds · CMS overall 5/533 citation rowsLas Brisas Rehabilitation And Wellness Center128 beds · CMS overall 5/524 citation rowsNorthgate Plaza120 beds · CMS overall 1/572 citation rowsThe Villages On Macarthur124 beds · CMS overall 2/541 citation rows