Grace & Mercy Assisted Living

Cited requirement:R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Provider-listed correction date: Mar 9, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.a. 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: 3. Includes the following: a. A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments;

Provider-listed correction date: Mar 16, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.3.e.i.1-4. 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: 3. Includes the following: 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 the resident requires assistance, (2) Psychotropic medications ordered for the resident, (3) Planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and (4) Goals for changes in the resident’s psychosocial interactions or behaviors; and

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

Cited requirement:R9-10-808.A.3.e.ii. 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: 3. Includes the following: e. For a resident who requires behavioral care: ii. Review by a medical practitioner or behavioral health professional; and

Provider-listed correction date: May 12, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.C.1.a-g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident’s service plan; b. Is only assigned to provide the assisted living services the caregiver or assistant caregiver has the documented skills and knowledge to perform; c. Provides assistance with activities of daily living according to the resident’s service plan; d. If applicable, suggests techniques a resident may use to maintain or improve the resident’s independence in performing activities of daily living; e. Provides assistance with, supervises, or directs a resident’s personal hygiene according to the resident’s service plan; f. Encourages a resident to participate in activities planned according to subsection (E); and g. Documents the services provided in the resident’s medical record; and

Provider-listed correction date: Apr 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;

Provider-listed correction date: May 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.C.13.b. Medical Records 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: b. The name, strength, dosage, and route of administration;

Provider-listed correction date: May 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-812.1-3. Behavioral Care A manager shall ensure that for a resident who requests or receives behavioral care from the assisted living facility, a behavioral health professional or medical practitioner: 1. Evaluates the resident: a. Within 30 calendar days before acceptance of the resident or before the resident begins receiving behavioral care, and b. At least once every six months throughout the duration of the resident’s need for behavioral care; 2. Reviews the assisted living facility’s scope of services; and 3. Signs and dates a determination stating that the resident’s need for behavioral care can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility

Provider-listed correction date: May 31, 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: May 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-817.B.3.c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident’s medical record.

Provider-listed correction date: Apr 15, 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: Mar 3, 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 15, 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: Mar 23, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-113.A.2.a-f. 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: 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, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom fr…

Provider-listed correction date: Apr 1, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-806.A.9. Personnel A. A manager shall ensure that: 9. Before providing assisted living services to a resident, a caregiver or an assistant caregiver receives orientation that is specific to the duties to be performed by the caregiver or assistant caregiver; and

Provider-listed correction date: Mar 31, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113

Provider-listed correction date: Mar 30, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.4.a. 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: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition; and

Provider-listed correction date: Dec 29, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-808.A.5.a-d. 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: 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.

Provider-listed correction date: Apr 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-811.C.13.a-d. Medical Records 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: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;

Provider-listed correction date: Apr 15, 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: Dec 23, 2025. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-812.1-3. Behavioral Care A manager shall ensure that for a resident who requests or receives behavioral care from the assisted living facility, a behavioral health professional or medical practitioner: 1. Evaluates the resident: a. Within 30 calendar days before acceptance of the resident or before the resident begins receiving behavioral care, and b. At least once every six months throughout the duration of the resident’s need for behavioral care; 2. Reviews the assisted living facility’s scope of services; and 3. Signs and dates a determination stating that the resident’s need for behavioral care can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility

Provider-listed correction date: May 15, 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: Apr 16, 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: Apr 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, and 2. The resident’s orientation is documented.

Provider-listed correction date: Apr 15, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.D.1. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 1. Immediately notifies the resident’s emergency contact and primary care provider; and

Provider-listed correction date: Mar 30, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-819.D.2.a-f. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: a. The date and time of the accident, emergency, or injury; b. A description of the accident, emergency, or injury; c. The names of individuals who observed the accident, emergency, or injury; d. The actions taken by the caregiver or assistant caregiver; e. The individuals notified by the caregiver or assistant caregiver; and f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.

Provider-listed correction date: Mar 30, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Provider-listed correction date: Dec 16, 2025. 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: Mar 30, 2026. A provider’s plan does not establish agency-confirmed correction.

Cited requirement:R9-10-820.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Provider-listed correction date: Mar 30, 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: 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, and ii. Controls 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, and ii. Controls 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: Apr 2, 2025. A provider’s plan does not establish agency-confirmed correction.