Grateful and Beyond Assisted Living LLC

Based on documentation review, interview, and record review, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. A review of the facility’s documentation revealed a policy titled, “Meeting Residents’ Needs During Night Time Hours” with the following verbiage, “At least the manager or a caregiver is present at the da when a resident is present in the facility...” 2. A review of the facility’s work schedule revealed E2 was scheduled as the only staff member present in the home during the nighttime shift hours for the month of March 2026. 3. In an interview, E2 and E3 reported that E2 was not a certified caregiver and that E2 would regularly work during night shift hours by themselves. 4. A review of E2's personnel record revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board). Therefore, E2 was not qualified to be left alone with the residents based on the lack of caregiver training. 5. A review of the azcg.tmutest.com website revealed no documentation of a caregiver training certificate for E2. 6. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record for two out of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1’s medical record revealed a service plan, which included the following: Checks every two hours, including night time checks. 2. A review of R1’s activities of daily living sheet revealed no documentation of two hour checks. 3. A review of R2’s medical record revealed a service plan, which included the following: Showering, three times a week; and Shampooing, three times a week. 4. A review of R2’s activities of daily living sheet revealed the following: Showering documented as given two times a week; and Shampooing, documented as given two times a week. 5. In an exit interview, the findings were reviewed with E3 and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on October 16, 2025.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the facility license revealed the facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E3, the Compliance Officer observed the back door of the facility, which led to the backyard, had an alarm; however, it did not make a sound when opening the door. The Compliance Officer also observed that this backyard door was not being monitored. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for one of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E2’s personnel record revealed a hire date of November 25, 2024. E2's personnel record did not include any documentation of fall prevention and recovery training. 2. In an exit interview, the findings were reviewed with E3 no additional information was provided.

Based on record review and interview, the health care institution failed to ensure that the health care institution established, documented, and implemented tuberculosis (TB) infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution, for two of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1's personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E2's personnel records revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "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, 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)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed one TB skin test with a negative result that was less than 12 months old. However, there was no documentation of a second TB skin or blood test showing evidence of freedom from infectious TB on or before the date the individual began providing services at the assisted living facility. Additionally, E1's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E1 had signs or symptoms of TB. 4. In an interview, E3 reported E1 had a hire date of December 4, 2024. 5. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification for one of two employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E1’s personnel record revealed a first aid and CPR training from the American Health and Safety Institute with an expiration date of September 2025. No additional trainings were found in E1's personnel record. 2. A review of the facility’s policies and procedures revealed a document titled, "ORIENTATION AND IN-SERVICE TRAINING" that included the following verbiage, "1. All employees and volunteers are required to receive orientation and training before delivering assisted living services to residents. PROCEDURES: All new employees and volunteers must complete orientation prior to commencing the provision of assisted living services. The orientation program will include: 22. CPR training verification and duty of care." 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy, as stated in R9-10-113 for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "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, 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)..." 2. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of occupancy, this documentation was required. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for two out of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1’s medical record revealed required services stated in their service plan, which included the following: Showering, three times weekly; Nail care, check nails daily and trim as needed; Oral care, daily; Shampoo, three times weekly and as needed; skin inspected daily; comb hair daily; incontinence checks; and laundry. 2. A review of R1’s medical record revealed no documentation of the above required services in accordance with the service plan. 3. A review of R2’s medical record revealed required services stated in their service plan, which included the following: Showering, three times weekly; Nail care, check nails daily and trim as needed; Oral care, daily; Shampoo, three times weekly and as needed; skin inspected daily; shave as needed; comb hair, two times daily; incontinence checks; daily maintenance of room and laundry; toilet cuing; and large muscle exercise two to three times a week. 4. A review of R2’s medical record revealed no documentation of the above required services in accordance with the service plan. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed a medication policy, however, there was no documentation of review and no signature from a medical practitioner, registered nurse, or pharmacist. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that medication was administered in compliance with a medication order and documented in the resident’s medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a signed medication order dated August 3, 2025. This order stated "Depakote 125mg 1 tab po every night". A review of R1's October 2025 medication administration record (MAR) revealed that Divalproex SOD DR, 125 mg, 1 tab po every night, was missing documentation of administration from October 1-14, 2025. 2. In a review of R1's medications, Divalproex was available. 3. A review of R2's medical record revealed a signed medication order dated August 4, 2025. This order stated "Risperidone 0.5mg 1 tab po twice daily". A review of R2's October 2025 MAR revealed that Risperidone, 0.5mg, 1 tab po twice daily, was missing documentation of administration on October 1-3 and 6-10, 2025. 4. In a review of R2's medications, Risperidone was not available. 5. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed the following unlocked medications within access of the residents of the facility: Calmoseptine ointment and Ketoconazole 2% Shampoo in R4's bedroom; Lispro insulin pen and Lantus insulin pen stored in the unlocked refrigerator in the kitchen; and Calmoseptine ointment in R1's bedroom 2. In an interview, R3 reported R1 and R4 did not self administer the medications. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility’s documentation revealed no disaster drills were available. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed two oxygen tanks in the bedroom of R2 that were standing in an upright position, however, neither oxygen tank was properly secured. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed the following unlocked poisonous or toxic materials within access of the residents of the facility: a bottle of Windex cleaning spray stored in an unlocked closet; a bottle of skin cleanser and Windex cleaning spray stored in a bathroom; a bottle of Febreze air freshening spray, Clorox wipes and Refrigerator cleaner in an unlocked caregiver sleeping room; ant killer stored in the food pantry, where food was also being stored; and clean freak chemical spray and dishwasher cleaning pods in an unlocked cabinet near the food pantry. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.