Ashford Hall
2021 Shoaf Dr, Irving, TX 75061 · Dallas County · 206 certified beds · avg 114 residents/day · certified since May 26, 1988
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Aug 10, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 11, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 4, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 5, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 4, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 5, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 22, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 23, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 22, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 24, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 25, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (35)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 24, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 24, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Dec 17, 2025 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 24, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jan 13, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint |
| Jan 13, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Sep 24, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Aug 10, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 10, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 17, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Apr 4, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 4, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 22, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 22, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Dec 1, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 1, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Nov 17, 2023 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. · from a complaint |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 11 | 5 | K ▲ |
| 2025 | 10 | 0 | E |
| 2026 | 8 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $301,255.
| Date | Type | Amount / length |
|---|---|---|
| Mar 4, 2026 | Fine | $15,935 |
| Sep 24, 2024 | Fine | $6,144 |
| Aug 10, 2024 | Fine | $22,391 |
| Mar 22, 2024 | Fine | $256,785 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.83 | 3.46 | 3.95 | top 20% in Texas; top 47% in the U.S. |
| Registered Nurse hours | 0.91 | 0.44 | 0.69 | top 4% in Texas; top 20% in the U.S. |
| Weekend total nurse staffing | 3.54 | 3.04 | 3.50 | top 15% in Texas; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.94 | 0.34 | 0.48 | top 1% in Texas; top 7% in the U.S. |
| Total nursing staff turnover (%) | 77.1 | 55.3 | 45.8 | bottom 14% in Texas; bottom 3% in the U.S. |
| RN turnover (%) | 75.9 | 54.6 | 42.9 | bottom 22% in Texas; bottom 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.71, RN 0.88, weekend 3.42. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Camas Investment Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/23/2007 |
| Lee, Darren | Individual | 5% or Greater Indirect Ownership Interest | — | 09/01/2019 |
| Lee, Michael | Individual | 5% or Greater Indirect Ownership Interest | — | 09/01/2019 |
| Lehi Investments Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/23/2007 |
| Lion Group of Companies, INC | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2000 |
| Lion Health Centers, INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2019 |
| Preferred Property Investments, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/01/1995 |
| Barrientos, Brenda | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/09/2017 |
| Barrientos, Brenda | Individual | ADP of the SNF | NOT APPLICABLE | 10/09/2017 |
| Benenate, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 01/03/2000 |
| Forvis Mazars LLP | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2016 |
| Jensen, Christian | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Karan Associates Two, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/15/1994 |
| Lee, Christopher | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/04/2025 |
| Lee, Darren | Individual | Corporate Director | NOT APPLICABLE | 09/01/2019 |
| Lee, Darren | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2019 |
| Lee, Darren | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2019 |
| Lee, Miriam | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/04/2025 |
| Lee, Nathan | Individual | Corporate Director | NOT APPLICABLE | 09/01/2019 |
| Lee, Nathan | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Irving | 1.1 mi | Irving, TX | ★★★★★ | 4/5 | |
| The Villages on Macarthur | 1.4 mi | Irving, TX | ★★☆☆☆ | 2/5 | abuse |
| Avante Rehabilitation Center | 1.4 mi | Irving, TX | ★★☆☆☆ | 2/5 | |
| Northgate Plaza | 2.1 mi | Irving, TX | ★☆☆☆☆ | 1/5 | |
| Las Brisas Rehabilitation and Wellness Center | 3.6 mi | Irving, TX | ★★★★★ | 5/5 | |
| Forest Park Nursing & Rehabilitation | 5.5 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| Lakewest Rehabilitation and Skilled Care | 6.0 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | abuse |
| Traymore Nursing Center | 6.5 mi | Dallas, TX | ★★★☆☆ | 4/5 | |
| Heritage at Turner Park Health & Rehab | 6.5 mi | Grand Prairie, TX | ★★☆☆☆ | 3/5 | |
| Brentwood Place Three | 6.8 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| South Dallas Nursing & Rehabilitation | 6.8 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| Brentwood Place One | 6.8 mi | Dallas, TX | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 455748.