Atria del Sol.

if not in the common areas. Six out of six staff state grooming and hygiene needs were being met although the resident would frequently refuse grooming as well as incontinence care. Facility staffing in memory care is as follows: Three caregivers/ med tech for 1st and 2nd shift depending on census and 1 caregiver/ med tech for NOC shift. The resident had a cat and six out of six staff state caring for the cat as well as cleaning the cat box. Due to the propensity of the cat to vomit and incontinence needs, carpet cleaning was conducted 1-2 times per week at a minimum and Maintenance confirms this service. Review of housekeeping records show the resident's room was being regularly cleaned. LPA observed no odors in the facility on three different visits. Physician order dated 02/05/2025 indicates resident was prescribed Seroquel 25mg the evening of 02/05/2025. Medication administration record shows the facility was waiting for the prescription to be filled prior to the resident being hospitalized for a urinary tract infection on 02/09/2025. Facility staff indicate insurance issues and a change in protocol of the pharmacy may have resulted in the delay in filling the prescription. Staff indicate an incident where the resident's family member was inadvertently told the resident had received the medication when in fact the medication was not on-site yet. LPA reviewed two physician orders for Tylenol and Ativan as routine medications following Atria's policy of no PRN medications in the memory care unit. Both were signed by R1's personal physician. Based on observations and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided to facility.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report dated 11/30/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 11/30/2025 indicated Resident 1 (R1) was walking down the hallway and fell. Maintenance Tech found the resident unresponsive at 10:45 AM and 911 was called. Resident was pronounced deceased at 11:00 AM at the facility. Physician report dated 02/06/2025 shows resident is diagnosed with Dementia. Facility notes indicate resident has had multiple falls in the facility. Facility to provide a copy of the death certificate upon receipt. LPA observed no health or safety concerns during today's visit. Exit interview conducted and a copy of this report was left at the facility. *This is an amended report to reflect a change in verbiage.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Atria Del Sol. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 64 ambulatory and 51 non-ambulatory of which 5 may be bedridden. Facility has an approved hospice waiver for 11 residents and the facility currently has 5 residents on hospice care. Jeremiah Goodwin has an administrator certificate expiring on 07/28/2025. LPA Lyman along with Administrator Goodwin toured the facility at 11:05 AM. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of three stories housing 63 apartments in assisted living, 27 apartments in memory care, multiple outside areas, two dining rooms, beauty salon, fitness area, movie theater, bistro and two activity areas. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.5 and 113.1 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors as well as a first aid manual. LPA observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and all were in range. Smoke detectors and fire inspections are conducted annually by an outside company, Systems Specialist, with the last inspection date in December 2024. CONTINUED ON LIC 809C DATED 05/13/2025 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Facility has carbon monoxide detectors in facility hallways and were tested to be operational. Fire extinguishers are fully charged. LPA observed evacuation chairs at stairwells. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed ample emergency food and water. LPA reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 03/30/2025. Facility provides activities in the form of games, exercise, and outings. LPA observed residents participating in activities during the visit. LPA spoke with residents during the visit who stated satisfaction with facility services and verbalized feeling safe. LPA observed no health or safety concerns during the visit. LPA reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, and criminal record clearance. Due to time constraints, LPA to return at a later date to review medication administration and storage. Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was given at time of visit.

Based on observations and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided to facility.

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Executive Director Jeremiah Goodwin, after identifying herself and stating the purpose of the inspection. This facility serves one hundred and twenty (120) residents 60 and above; 64 ambulatory, 51 may be non-ambulatory, in which Five (5) residents may be bedridden, includes a 31 bed dementia unit with delayed egress. Hospice waver for 11. LPA was accompanied by Executive Director Goodwin during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. The facilities has three stories with the memory unit on floor two. Signal systems are in place and operational. PPE supplies are onsite. Passageways were free from obstructions. Facility does feature delayed egress doors on the second floor.. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid strips. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in a medication room and medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with Executive Director Goodwin, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Executive Director Goodwin.

staff S2 indicated that a call was made to R1’s POA when this occurred and that any time there was any adverse reaction or behavior with R1. S2 indicated that they have made those calls and indicated that R1’s POA is very involved with the care of R1 and therefore staff are very mindful of always providing information to POA. It is alleged that staff left resident in soiled diapers for an extended period of times. LPA conducted a site visit on June 10, 2024, and was unable to make observations to R1 as R1 had moved out of the facility May 01, 2024. Interviews with 1 of 2 staff indicated that R1 could get very combative at times and did not allow for staff to give R1 proper care until R1 would calm down. Based on the information available through record review and interviews, LPA is unable to corroborate or refute that a violation occurred as alleged as the information collected is conflicting. It is alleged that staff overmedicated resident. Records review MAR for January – May 2024 indicates that medication was given to R1 as indicated in prescription directions. MARs reflect that medication was given at the scheduled time per order indications. Interview with 1 of 2 staff revealed that medication is given as prescribed and there is no way staff can over medicate because that would cause a shortage on dosage that was needed for R1 to be given dosage as indicated per day. Staff indicated this would reflect on MAR, but however dosages are signed off as given as indicated on prescription instructions. It is alleged that staff did not notify authorized representative of new medication. Records revealed copies of doctor’s orders for medication on file for R1, and a completed MAR sheet for all medication for resident. Interview with 2 of 2 staff revealed that they would inform POA of anything that involved R1’s care. POA was very involved with residents’ care therefore staff at facility kept POA informed of care. Staff indicated that once ordered are received by the physician the medication is given according to the physician's directions. Based on the information available through record review and interviews, LPA is unable to corroborate or refute that a violation occurred as alleged as the information collected is conflicting. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Goodwin. A copy of this report was provided and explained.