Aphz, LLC

Based on observation, the facility failed to ensure its fire doors fully closed and latched securely upon release. The facility failed to ensure that resident room doors were in good working order. Failing to protect resident sleeping rooms from heat or smoke could cause harm to the resident and staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3 Corridor DoorsSection 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.Findings include:Observations made while on tour on July 1, 2025, revealed the following;Room #511 did not close and latch securely when closed.Rooms #537, #536, #532, and #512 had excessive gaps more than 1/8th inch at the top of the door.Room #504 had a door mag lock device pulled out of the wall when attempting to close the door.Room #504, the door failed to close and latch securely.During the exit conference on July 1, 2025, the above findings were again acknowledged by the Executive Director and Director of Maintenance.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switchfor the generator was installed. This could affect the entire facility and could result in a loss of powerdue to a generator malfunction during an emergency power outage. Failure to have an emergency stopon the generator could cause a fire or harm the residents and/or staff.Code reference: NFPA 110, 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 Allinstallations shall have a remote manual stop station of a type to prevent inadvertent or unintentionaloperation, located outside the room housing the prime mover, where so installed, or elsewhere on thepremises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors,The manual shutdown should be located external to the weatherproof enclosure and should beappropriately identified.Findings include:During observations during a tour conducted on July 1, 2025, it was revealed that the facilitygenerator did not have the required remote stop or kill switch. Per facility management, this switch iscurrently out for bid.The management team confirmed during the facility tour and the exit conference on July 1, 2025,that the facility did not have an emergency shut-off for the generator.

Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of misappropriation for one resident (#38) was reported to the State Agency within the required time frame of twenty-four hours.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was processed for determination of need for PASRR level II for one resident (# 42). The deficient practice could result in residents not receiving the appropriate services they need.

Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure adequate supervision was provided for one resident (#204), in a public area who was exploited by assisted living staff. The deficient practice could result in residents being exploited.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of misappropriation for one resident (#38) was reported to the State Agency within the required time frame of twenty-four hours.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was processed for determination of need for PASRR level II for one resident (# 42). The deficient practice could result in residents not receiving the appropriate services they need.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide continence and shower care according to professional standards for one resident (#102). The deficient practice could result in skin breakdown.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure weekly skin assessments were provided for one resident (#21) of three sampled residents, as ordered by the physician and failed to ensure that physician orders for one resident (# 28) for diagnostic testing were addressed in a timely manner following an unwitnessed fall. The deficient practice could lead to an injury being missed and a delay in care being provided to the resident and result in skin impairments developing or worsening without staff intervention.

The facility failed to provide and environment free from accident hazards for one resident (#21) and failed to ensure adequate supervision to ensure one resident (#105) did not elope. The deficient practice could result in residents being injured, abused, or lost.

Based on personnel file review, interviews, and policy review, the facility failed to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants (CNA/Staff #12). The deficient practice could result in insufficient and inadequate care for residents.

Based on observation, staff interviews, and policy review, the facility failed to ensure that medications were dated when opened. The deficient practice could result in reduced drug effectiveness and adverse reactions.

The facility failed to ensure appropriate infection control measures were implemented and followed for one resident (# 44) related to tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure adequate supervision was provided for one resident (#204), in a public area who was exploited by assisted living staff. The deficient practice could result in residents being exploited.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide continence and shower care according to professional standards for one resident (#102). The deficient practice could result in skin breakdown.

Based on observation, staff interviews, and policy review, the facility failed to ensure that medications were dated when opened. The deficient practice could result in reduced drug effectiveness and adverse reactions

The facility failed to ensure appropriate infection control measures were implemented and followed for one resident (# 44) related to tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.

The facility failed to provide and environment free from accident hazards for one resident (#21) and failed to ensure adequate supervision to ensure one resident (#105) did not elope. The deficient practice could result in residents being injured, abused, or lost.