Villas at Sunny Acres, the

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Meet other general requirements that are deficient.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Prepare residents for a safe transfer or discharge from the nursing home.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Based on a record review and staff interview, it was determined that the facility failed to maintain the elevator components and devices in accordance with NFPA 101. 1.Elevator cert available for review is expired 9.4.6 Elevator .. Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Fire Alarm report stated (4 water-.. Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1.Fire Alarm reports shows (releasing devic.. Based on observation and staff interview, it was determined that the facility did not maintain Evacuation and Relocation Plans iaw NFPA 101. 1. Emergency plans need updating (to include dialing 911 and evacuation of effected .. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain electrical equipment in accordance with Life Safety Code. and NFPA 701.Cracked red outlet in memory careNFPA 70 (11.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.4.5.11.Longs hallway egress doors racked (difficult to op.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1.Sign-age on doors need to be changed ou.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Gas shut off module getting burned (Facility need replace damaged gas module and ensure n.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Fire Doors (Multiple fire doors show as failed on inspection report)2. Rooms 721, 743 have door gaps3. Long ha.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1.Door closer by shower room rainbow 2. Room 749 door not latching NFPA 80 5.2.1* Fire door assemblies .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Sprinkler Annual Re.. During the survey, it was determined that the facility trans-fill room did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Ventilation in Oxygen transfer room .. During the survey, it was determined that the facility trans-fill room did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Ventilation in Oxygen transfer room .. During the survey, it was determined that the facility trans-fill room did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Ventilation in Oxygen transfer room .. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a).This facility consists of three (3) buildings. Building A1 (Health Care Center) is connected to Building A2 (Rainbow Annex) and has a two (2) h..

A recertification survey with complaint #CO37020, #CO37260, #CO38675, #CO39462, #CO39464 and #CO39468 was completed on 3/31/25 to 4/3/25. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 3/31/25 to 4/3/25. No deficiencies were cited. Based on observations and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include: I. Facility policy and procedureThe Palatable Food policy and procedure, revised October 2021, was provided by the food and n.. Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of seven units. Specifically, the facili.. Based on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#276) of one resident out of 49 sample residents.Specifically, the facility.. Based on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to prevent an elopement from the secured unit building for Resident #276. Findings include:I. Facility .. Based on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADL' s) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (#326 and #8) of five residents out of 49 sample residents. Specifically the facility failed to -Offer re.. Based on observations, record review, and interviews, the facility failed to ensure all drugs and biologics were properly stored and labeled for one (#101) of two residents reviewed out of 49 sample residents. Specifically, the facility failed to ensure medications that were not administered were not left unsecured at Resident #101' s bedside. .. Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record one (#376) of five residents reviewed for advance directives out of 49 sample residents. Specifically, the facility failed to ensure:-Resident #376 had a physician' s order for their cardiopulmonary resuscitation (CPR) wishes i.. Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#116) of two residents reviewed for dialysis out of 49 sample residents. Specifically, the facility failed to: -Consistently and thoroughly complete the dialysis com.. Based on record review and interviews, the facility failed to inform the resident' s representative of the change in condition for one (#176) out of five residents reviewed out of 49 sample residents.Specifically, the facility failed to timely notify Resident #176' s representative of a fall, the need for medical imaging (Xray) of her left hip, new orders ..