Golden Heart LLC

Based on documentation review, record review, and interview, the assisted living home failed to either administer or to provide documentation of completed Fall Prevention and Fall Recovery training as required by A.R.S. § 36-420.01.A, for three of three personnel reviewed. The deficient practice posed a risk to the physical health and safety of a resident. 1. A.R.S. § 36-420.01(A) states "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." 2. A review of E1's personnel record revealed that E1 did not have documentation of completed Fall Prevention/Fall Recovery training available for review at the time of the inspection. 3. A review of E2's personnel record revealed that E2 did not have documentation of completed Fall Prevention/Fall Recovery training available for review at the time of the inspection. 4. A review of personnel records revealed that E3 did not have a personnel record, and therefore, E3 did not have documentation of completed Fall Prevention/Fall Recovery training available for review at the time of the inspection. 5. In an interview, E1 stated that both E1 and E2 had completed Fall Prevention/Fall Recovery training, but acknowledged that documentation of the completed training was not available for review at the time of the inspection. E1 also acknowledged that E3 did not have documentation of completed Fall Prevention/Fall Recovery training available for review at the time of the inspection.

Based on observation, record review, and interview, the manager failed to designate in writing a caregiver who was present on the assisted living home’s premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the on-site management of the assisted living facility. Findings include: 1. Upon arrival, the Compliance Officer observed E2 and E3 working at the home. No other staff was at the home. Further observation revealed a posting on the wall titled "DELEGATION OF AUTHORITY." The document read as follows: "The Governing Body of Coolidge Legacy Assisted Living who is/are the governing authority of this assisted living facility and owned by Otilia Muresan & David Muresan hereby delegates Shaista Hana Hamed in directing and supervising the operation as the Manager, of this Assisted Living Facility and providing care to the residents. In the absence of the Manager, the caregiver/s namely: Elaine French (Day Shift) and Olilia Muresan (Night Shift) are empowered to act on the Manager's behalf in directing and supervising the operation of this Assisted Living Facility and providing care to the residents." This form was signed and dated on May 1, 2022. There was no other documentation posted or available for review that pertained to the Golden Heart LLC. 2. In an interview, when asked, E2 reported that E2 was the sole caregiver and that E1 only came by the house randomly on occasion. 3. A review of E2's personnel record revealed no documentation related to the delegation of the manager's authority. In the packet of personnel papers that E1 later printed and provided to the Compliance Officer for E2, there was a form titled "Delegation of Manager's Authority". The form stated, "The following named caregiver has agreed to accept this responsibility as evidenced by signing this form...Date when this authorization begins: 10/15/2025." The form was not signed by E1 or E2. 4. In an interview, E1 reported that E1 lived far from the assisted living home (45 minutes) and that it was not convenient for E1 to come to the home. E1 acknowledged that E1 failed to designate in writing a caregiver who was present at the assisted living home and accountable for the assisted living facility when E1 was not present.

Based on record review, interview, and documentation review, the manager failed to ensure that before providing assisted living services to a resident, a caregiver's or an assistant caregiver's skills and knowledge were verified and documented, for two of two applicable personnel reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E2's personnel record revealed that E2 did not have skills and knowledge verified and documented as required. E1 later provided the Compliance Officer a form titled "Employee Qualification and Skills" printed out from the computer for E2; however, the form was not complete. The form stated, "The caregiver or assistant caregiver has demonstrated and skills and knowledge have been verified before providing physical health services or behavioral health services for each item that was initialed." None of the skills had been initialed by E2 as required and E1 had not signed the form as the signature of the "Person performing the evaluation and verification." 2. A review of personnel records revealed that E3 did not have a personnel record, and therefore, E3 did not have skills and knowledge verified and documented. 3. In an interview, E1 stated that E1 did verify E2's skills and knowledge, but that E2 couldn't complete the form because it was on the computer. E1 acknowledged that E2 did not initial each skill as proof of demonstration and that E1 did not sign off on the form as required. E1 also acknowledged that E3's skills and knowledge had not been verified and documented yet.

Based on documentation review and interview, the manager failed to ensure that documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as required information could not be verified for the employees. Findings include: 1. Upon arrival, the Compliance Officer observed two staff on-site and working at the home. The first staff member was identified as E2, and the second as E3. 2. A review of the "Employee Work Schedule" that was posted on the front wall revealed the schedule was from the previous owner of the home, "Coolidge Legacy At Scottsdale." The schedule was for October 2025, and contained the names of employees from the previous ownership. Neither E2 or E3 had a documented schedule, nor was there a current schedule for the facility available for review. 3. In an interview, E1 acknowledged that an employee schedule was not available for review.

Based on record review, interview, and documentation review, the manager failed to ensure that before providing assisted living services to a resident, a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed, for three of three personnel reviewed. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E1's personnel record revealed that E1 did not have documentation of completed orientation available for review at the time of the inspection. 2. A review of E2's personnel record revealed that E2 did not have documentation of completed orientation available for review. E1 later provided the Compliance Officer an orientation form for E2 and stated that E2 had completed orientation upon hire but never signed the form to acknowledge E2 had completed orientation. 3. A review of personnel records revealed that E3 did not have a personnel record, and therefore, E3 did not have documentation of completed orientation. 4. In an interview, E1 stated that E1 had completed orientation but hadn't put the paperwork in E1's personnel record. E1 acknowledged that E1 did not have an orientation form available for review at the time of the inspection. E1 also acknowledged that E2 had not signed E2's orientation form to acknowledge completion of E2's orientation; and that E3 had not completed orientation yet.

Based on observation, documentation, record review, and interview, the manager failed to maintain a personnel record for each employee as required by R9-10-806.C.1.a-c, for one of three employees. The deficient practice posed a risk as required information could not be verified for an employee. Findings include: 1. Upon arrival, the Compliance Officer observed two staff on-site and working at the home. The first staff member was identified as E2, and the second as E3. 2. A review of the "Employee Work Schedule" that was posted on the front wall revealed the schedule was from the previous owner of the home, "Coolidge Legacy At Scottsdale." The schedule was for October 2025, and contained the names of employees from the previous ownership. Neither E2 or E3 had a documented schedule, nor was there a current schedule for the facility available for review. 3. In an interview, E2 stated E2 was a caregiver. When asked if E3 was a caregiver, E3 responded, "Yeah, I work here." 4. There were no personnel records available for review inside the home. Upon E1's arrival, E1 retrieved partial personnel records from a locked cabinet outside in the side yard. 5. A review of personnel records revealed E3 did not have a personnel record. 6. In an interview, E3 stated that E3's first day of work was the day prior to the inspection. 7. In an interview, E1 acknowledged that E3 did not have a personnel record. E1 stated that E3 only came to the house yesterday and that E1 was planning to complete E3's personnel paperwork the day of the inspection. E1 also stated that E3 would be living at the home.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in R9-10-113, for three of three residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's medical record revealed a completed TB Screening and Risk Assessment; however, there was no documentation of evidence of freedom from infectious TB. Based on R1's date of admission, this documentation was required. 2. A review of R2's medical record revealed there was no documentation of a TB Screening and Risk Assessment, nor was there documentation of evidence of freedom from infectious TB. Based on R2's date of admission, this documentation was required. 3. A review of R3's medical record revealed a completed TB Screening and Risk Assessment; however, there was no documentation of evidence of freedom from infectious TB. Based on R3's date of admission, this documentation was required. 4. In an interview, E1 acknowledged there was no documentation of evidence of freedom from TB for R1, R2, and R3 available for review at the time of the inspection. In addition, there was no TB Screening and Risk Assessment available for review for R2.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility, and if an individual was expected to receive supervisory care services, personal care services, or directed care services, the documentation included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant for two of three residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a form titled "Determination and Authorization for Continued Residency." The form did not include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. 2. A review of R2's medical record revealed there was no admitting documentation to indicate R2's expected level of care that included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints, and that was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 3. In an interview, E1 stated the doctor did not send back the second page of the form for R1, which included whether R1 would require continuous medical services, continuous or intermittent nursing services, or restraints. E1 also stated that E1 had the admitting documentation for R2, but that it was in E1's email somewhere. E1 acknowledged R1 and R2 did not have the required admitting documentation for R1 and R2 available for review at the time of the inspection.

Based on record review, observation, and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which was completed no later than 14 calendar days after the resident’s date of acceptance for one of one applicable resident reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed R1 did not have a service plan. Based on R1's date of acceptance into the home, this documentation was required. 2. In an interview, R1 reported concerns with not receiving adequate services. R1 stated that R1 had a nebulizer machine delivered to the home, but the care staff had not assisted with getting the necessary medication that goes in the nebulizer. R1 stated that R1 had requested on several occasions for a new or different device that goes over the toilet because the current device causes R1 to almost fall every time R1 tries to use the toilet. R1 stated that R1 did not have a call pendant or a means to alert staff in the event R1 needed assistance. 3. The Compliance Officer observed R1's bedroom. There was a nebulizer machine sitting on a shelf, still in the original package and not being used. The assistive device over R1's toilet was unstable and did not properly fit over the toilet. R1 did not have a means to call care staff in the event R1 needed assistance. 4. In an interview, E1 acknowledged R1 did not have a service plan as required.

Based on observation, interview, and record review, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record for nine of nine applicable residents. The deficient practice posed a risk as services could not be verified as provided against a service plan or as being needed or provided. Findings include: 1. Upon arrival, the Compliance Officer requested either Medication Administration Records (MAR's) or Activities of Daily Living (ADL's) for each of the residents or the residents' individual medical records from E2. The Compliance Officer observed there were no binders to indicate MAR's or ADL's, nor were there any resident binders available for review. 2. In an interview, E2 stated there were no MAR's, ADL's, or resident records available because the facility did not document medication administration or ADL's, and E2 did not know where the resident records were located. 3. Upon arrival to the facility, E1 acknowledged there was no record of medication administration or documentation of ADL's. 4. E1 brought in partial medical records from outside in the side yard area. A review of R1, R2, and R3's partial medical records confirmed there had been no history of ADL's documented. The remaining six medical record binders for R4, R5, R6, R7, R8, and R9 were not put together yet and did not contain ADL's either. 5. In an interview, E1 acknowledged E1 failed to ensure that a caregiver or an assistant caregiver documented the services provided to the residents in each of the resident’s medical records for the nine applicable residents.

Based on observation, documentation review, and interview, the manager failed to ensure that daily social, recreational, or rehabilitative activities were planned according to residents’ preferences, needs, and abilities; a calendar of planned activities was prepared and posted in a location that was easily seen by residents, and maintained for at least 12 months after the last scheduled activity; and that multiple media sources, such as daily newspapers, current magazines, internet sources, and a variety of reading materials, were available and accessible to a resident to maintain the resident’s continued awareness of current news, social events, and other noteworthy information. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed an "ACTIVITIES" calendar posted from "Coolidge Legacy at Scottsdale LLC" from October 2025. The ownership of the assisted living home changed from Coolidge Legacy at Scottsdale, LLC to Golden Heart, LLC on October 15, 2025. 2. A review of facility documentation revealed there had been no other activities calendar prepared and posted since the previous ownership. 3. In an interview, E1 acknowledged that E1 had failed to post a calendar of planned activities since taking over ownership of the facility in October 2025.

Based on observation, interview, and record review, the manager failed to ensure a resident was treated with dignity, respect, and consideration for two of two applicable residents reviewed. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed R1's bedroom to be tight based on the hospital bed placement, which blocked R1's access to R1's walker and the closet. R1 was in a wheelchair, which took up most of the remaining room. R1 used oxygen, so there were oxygen cords on the floor. There was an assistive device over R1's toilet that did not appear to properly fit the toilet. There was a urine container lying on its side on the floor, partially sticking out from under the bed. There were several (at least three) used adult briefs filling up the bathroom trash can that was not lined with a liner or trash bag. There was a roll of toilet paper on the floor behind the toilet, and other sitting on the tank of the toilet because there was no toilet paper holder affixed to the wall. 2. In an interview, R1 reported concerns with the care R1 was receiving at the home. R1 stated that R1 was not getting all of the medication R1 needed. R1 stated that R1 had requested on several occasions for a new or different device that goes over the toilet because the current device causes R1 to almost fall every time R1 tries to use the toilet. R1 stated R1 did not have a call pendant since being moved to a different room, but also said, "What good would it do anyways?;" suggesting that the caregiver doesn't respond timely to requests for assistance. R1 stated R1 was moved to a different room while R1 was not present, and R1's items were moved by the caregiver(s). R1 stated that R1 was missing some property after the move. When asked if R1 felt R1 was treated with dignity, respect, and consideration, R1 responded, "No." 3. While on-site, the Compliance Officer heard R2 yelling for several minutes, saying, "What are you doing to me? Why are you doing that? What are you doing? Ouch! What are you doing?" while being changed by E2 and E3. During the 10-15 minutes that E2 and E3 were changing E2's brief and bed linens, neither E2 nor E3 said anything to R2, even as R2 was yelling and asking questions. 4. A review of R2's medical record revealed a "Resident Health History" form that had been completed during R2's admission. Under the "Memory Care and Elopement Risk Assessment" section, the form indicated that R2 required "Behavioral support during ADLs," but the remaining part of that section was not completed to suggest what type of support R2 needed. 5. While on-site, the Compliance Officer observed another resident sitting in the living room. For several hours, the resident attempted to get anyone's attention possible. E2 and E3 had been tending to R2 and other residents in the back of the house; therefore, they were unable to assist the resident. The resident attempted to speak with the Compliance Officer but could only speak in S

Based on observation and interview, the manager failed to ensure a resident was not subjected to misappropriation of personal and private property by the caregivers or assistant caregivers for one of one applicable resident reviewed. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed R1 in R1's bedroom. There was a nebulizer machine on a nightstand in what appeared to be the original packaging. 2. In an interview, R1 stated R1 was not getting all of the medication R1 needed. R1 stated R1 had received a nebulizer but didn't have the medication R1 needed to go into the nebulizer. R1 stated R1 was moved to a different room while R1 was not present, and R1's items were moved by the caregiver(s). R1 stated R1 was missing some property after the move. R1 also stated R1 did not have a call pendant since being moved to a different room. 3. In an interview, the findings were reviewed with E1 and no additional statements were provided regarding the findings.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for three of three residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1, R2, and R3's partial medical records revealed R1, R2, and R3 did not have signed medication orders available for review at the time of the inspection. 2. In an interview, E1 reported that E1 had not put together each of the residents' medical records but that each of the residents were administered medications according to medication orders. E1 acknowledged that E1 failed to ensure that each of the resident’s medical records contained medication orders from a medical practitioner for each medication that was administered.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom for one of one applicable residents sampled receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed that R1 did not have a bell or call pendant in R1's bedroom to alert employees to R1’s needs or emergencies if necessary. 2. In an interview, R1 stated that R1 had a call pendant when R1 was in Room 4. But when the caregiver moved R1 from Room 4 to Room 6, R1 no longer had a call pendant available. 3. In an interview, E1 asked R1 where R1's call pendant was. R1 explained that R1 didn't get a call pendant upon moving to Room 6, and therefore, R1 did not have a call pendant. 4. E1 checked R1's room while the Compliance Officer was present and was unable to locate a call pendant. 5. In an interview, E1 acknowledged R1 did not have a call pendant, bell, or other mechanical means to alert employees to R1's needs or emergencies.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom for one of one applicable resident receiving directed care services. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed that R2 did not have a bell or call pendant available and accessible in R2's bedroom to alert employees to R2’s needs or emergencies if necessary. 2. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

Based on record review and interview, the manager failed to ensure that staff obtain a certificate of completion, as specified in R9-10-126, including the minimum eight hours of initial memory care services training within the first 30 days of hire for one of two applicable staff. The deficient practice posed a risk if the employee was unable to meet a resident's needs. Findings include: 1. A review of E2's personnel record revealed that E2's date of hire was October 15, 2025. Further review revealed that E2 had not obtained a certificate of completion for the minimum eight hours of initial memory care services training within the first 30 days of hire. 2. In an interview, E2 reported E2 was the primary caregiver at the home. 3. In an interview, E1 confirmed E2 was the primary and live-in caregiver at the home. E1 acknowledged E2 had not completed the required memory care training as specified in R9-10-126.

Based on record review and interview, the manager failed to ensure that a resident’s medication was administered to the resident in compliance with a medication order from a medical practitioner for each medication that was administered to the resident for three of three residents sampled. The deficient practice posed a risk as the medication administered could not be verified against a medication order. Findings include: 1. A review of R1, R2, and R3's partial medical records revealed that R1, R2, and R3 did not have signed medication orders available for review at the time of the inspection. 2. In an interview, E1 reported that E1 had not put together each of the residents' medical records but that each of the residents was administered medications according to medication orders. E1 acknowledged that E1 failed to ensure that each of the residents’ medical records contained medication orders from a medical practitioner for each medication that was administered.

Based on observation, interview, and record review, the manager failed to ensure that medication administered to a resident was documented in the resident’s medical record for nine of nine applicable residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Upon arrival, the Compliance Officer observed there were no visible medical records or Medication Administration Records (MARs) available for review, at which point the Compliance Officer asked E2 to provide them. 2. In an interview, E2 stated there were no MARs because the facility did not document medication administration, and E2 did not know where the resident records were located. E2 stated that E2 had a key to the medication cart and administered medications to all of the residents. 3. Upon arrival to the facility, E1 acknowledged there was no documentation of medication administration. 4. E1 retrieved partial medical records from outside in the side yard area. 5. A review of R1, R2, and R3's partial medical records confirmed there had been no history of medication administration documented. The remaining six medical record binders for R4, R5, R6, R7, R8, and R9 were not fully put together yet and did not contain documentation of medication administration either. 6. In an interview, E1 acknowledged that E1 failed to ensure that medication administered to a resident was documented in the resident’s medical record for the nine applicable residents.

Based on observation, documentation review, and interview, the manager failed to ensure that a food menu was prepared at least one week in advance, and included the foods to be served each day, was conspicuously posted at least one calendar day before the first meal on the food menu was served, included any food substitution no later than the morning of the day of meal service with a food substitution, and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed a menu posted from "Coolidge Legacy at Scottsdale LLC." The ownership of the assisted living home changed from Coolidge Legacy at Scottsdale, LLC to Golden Heart, LLC on October 15, 2025. 2. A review of facility documentation revealed there had been no food menu prepared and posted since the previous ownership. 3. In an interview, E2 and E3 stated there was no menu to follow and that E2 and E3 just make whatever is available. 4. In an interview, E1 explained E1 had current menus on E1's computer but just hadn't printed and posted them yet. E1 acknowledged that E1 had failed to conspicuously post a food menu since taking over ownership of the facility in October 2025.

Based on observation and interview, the manager failed to ensure that meals and snacks provided by the assisted living facility were served according to posted menus. Findings include: 1. While on-site, the Compliance Officer observed a menu posted from "Coolidge Legacy at Scottsdale LLC." The ownership of the assisted living home changed from Coolidge Legacy at Scottsdale, LLC to Golden Heart, LLC on October 15, 2025. 2. In an interview, E2 and E3 stated there was no menu to follow and that E2 and E3 just make whatever is available. 3. In an interview, E1 explained E1 had current menus on E1's computer but just hadn't printed and posted them yet. E1 acknowledged that E1 failed to ensure that meals and snacks provided by the assisted living facility were served according to posted menus.

Based on record review and interview, the manager failed to ensure that a resident received 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 the resident’s orientation was documented, for two of three residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1's and R3's medical records revealed there was no documentation of R1's and R3's orientation to exits from the assisted living facility. Based on R1's and R3's dates of acceptance into the facility, this documentation was required. 2. In an interview, E1 acknowledged that E1 failed to ensure that R1 and R3 received orientation to the exits from the assisted living facility and the route to be used when evacuating within 24 hours after R1’s and R3's acceptance by the assisted living facility, and that the orientation was documented.

Based on observation, interview, and record review, the manager failed to ensure that the facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. While on-site for the complaint inspection, the Compliance Officer observed R1's bedroom to be tight based on the hospital bed placement, which blocked R1's access to R1's walker and the closet. R1 was in a wheelchair, which took up most of the remaining room. R1 used oxygen, so there were oxygen cords on the floor. There was an assistive device over R1's toilet that was unstable and did not appear to properly fit the toilet. 2. In an interview, R1 reported concerns with the care R1 was receiving at the home. R1 stated that R1 had requested on several occasions a new or different device that goes over the toilet because the current device causes R1 to almost fall every time R1 tries to use the toilet. 3. In an interview, the findings were reviewed with E1, and no additional comments or statements were provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were in a locked and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Upon arrival to the facility at approximately 10:00 AM, the Compliance Officer observed the kitchen cabinet under the sink to have a "Master" brand combination lock hanging open (unlocked) on the cabinet. The cabinet contained a number of poisonous or toxic materials including: a 121-ounce container of "Clorox Disinfecting Bleach;" a 128-ounce container of "Fabuloso Multi-Purpose Cleaner;" a 32-ounce spray bottle of "Clorox Urine Remover;" a spray can of "Pledge" Furniture Polish, a bottle of "Soft Scrub;" a box of "S.O.S." steel wool soap pads; a bottle of "Method Multi-Purpose Cleaner;" and various other miscellaneous cleaning and disinfectant supplies. 2. During the inspection, the Compliance Officer observed two ambulatory residents in the kitchen and living room area, with no staff members present. 3. Upon E1's arrival to the facility at approximately 11:30 AM, the Compliance Officer advised E1 that the cabinet was unlocked since 10:00 AM and had remained unlocked. 4. In an interview, E1 acknowledged the cabinet containing various poisonous or toxic materials stored by the assisted living facility was not locked, leaving the poisonous or toxic materials accessible to residents.