God'S Grace Assisted Living LLC

Cited requirement:R9-10-803.C.1.k.iii. Administration C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: k. Cover the provision of assisted living services, including: iii. Obtaining resident preferences for food and the provision of assisted living services;

Provider-listed correction date: Aug 21, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.1-5. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 1. Is completed no later than 14 calendar days after the resident’s date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident’s representative, b. The manager, and c. Any individual requested by the resident or the resident’s representative; 3. Includes the following: a. A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; b. The level of service the resident is expected to receive; c. The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner; e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident’s psychosocial interactio…

Provider-listed correction date: Aug 24, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-810.B.1. Resident Rights B. A manager shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

Provider-listed correction date: Aug 22, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.A.1.a-g. Medication Services A. A manager shall ensure that: 1. Policies and procedures for medication services include: a. Procedures for preventing, responding to, and reporting a medication error; b. Procedures for responding to and reporting an unexpected reaction to a medication; c. Procedures to ensure that a resident’s medication regimen and method of administration is reviewed by a medical practitioner to ensure the medication regimen meets the resident’s needs; d. Procedures for: i. Documenting, as applicable, medication administration and assistance in the self-administration of medication; and ii. Monitoring a resident who self-administers medication; e. Procedures for assisting a resident in procuring medication; f. If applicable, procedures for providing medication administration or assistance in the self-administration of medication off the premises; and g. Procedures for administering medication to residents receiving memory care services; and

Provider-listed correction date: Aug 22, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.F.3.a. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication;

Provider-listed correction date: Aug 27, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Provider-listed correction date: Aug 22, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Provider-listed correction date: Aug 13, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.

Provider-listed correction date: Jul 18, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exp…

Provider-listed correction date: Aug 13, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and

Provider-listed correction date: Aug 13, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Provider-listed correction date: Aug 13, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 1. Policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander; 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility that is secure, and ii. Monitors or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Provider-listed correction date: Jul 20, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Provider-listed correction date: Aug 7, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Provider-listed correction date: Jul 20, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Correction information is not available in the records reviewed.

Cited requirement:A. A governing authority shall: 8. Ensure that a manager or caregiver who is able to read, write, understand, and communicate in English is on an assisted living facility's premises; and

Correction information is not available in the records reviewed.

Cited requirement:B. A manager: 3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: b. Present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers;

Correction information is not available in the records reviewed.

Cited requirement:A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Correction information is not available in the records reviewed.

Cited requirement:B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours:

Correction information is not available in the records reviewed.

Cited requirement:A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident's representative, b. The manager, and c. Any individual requested by the resident or the resident's representative; 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; b. The level of service the resident is expected to receive; c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication; d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner; e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident's psychosocial interactions to manage the resident's behavior: (1) The psychosocial interactions or behaviors for which…

Correction information is not available in the records reviewed.

Cited requirement:A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Correction information is not available in the records reviewed.

Cited requirement:C. A manager shall ensure that a resident's medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and

Correction information is not available in the records reviewed.

Cited requirement:F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: d. Storing, inventorying, and dispensing controlled substances.

Correction information is not available in the records reviewed.