THE VILLAS AT SUNNY ACRES

The information listed below provides an in-depth look into the type and quality of care offered at The Villas at Sunny Acres. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

THE VILLAS AT SUNNY ACRES
2501 E 104TH AVE
THORNTON, CO 80233
(303) 452-4181

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

87%

Number of Residents and Certified Beds

  • Residents: 139
  • Certified Beds: 160

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Corporation
  • Offers Both Resident and Family Counseling Services
  • Part of a Continuing Care Retirement Community (CCRC)
  • This Facility is Part of a Chain or Franchise

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Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by The Villas at Sunny Acres. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-1624.3%
ADL Index Range: 6-1043.0%
ADL Index Range: 0-515.7%
Total Percent:83.0%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 6-1014.3%
ADL Index Range: 0-52.6%
Total Percent:17.0%
 

Rating Details For The Villas at Sunny Acres

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours54 Minutes60 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours30 Minutes37 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 40 Minutes2 Hours and 26 Minutes
Total Licensed Nurse Hours1 Hour and 24 Minutes1 Hour and 36 Minutes
Total Nurse Hours4 Hours and 4 Minutes4 Hours and 2 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Colorado are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityColorado Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%88%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%87%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Are More Depressed or Anxious16%16%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection11%9%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse11%11%
Percent of Long-Stay Residents Who Lose Too Much Weight4%8%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder4%7%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased22%15%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores12%9%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores3%3%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair2%3%
Percent of Long-Stay Residents Who Were Physically Restrained6%4%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain1%4%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder58%48%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%79%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90-100%81%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Pressure Sores6%9%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain12%23%
Percent of Short-Stay Residents Who Have Delirium1%3%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 04/15/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Administration

Keep Accurate and Appropriate Medical Records.
  • Inspection Date: 07/31/2008
  • Correction Date: 10/10/2008

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/29/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Provide Needed Housekeeping and Maintenance.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/28/2008
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/29/2008
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Pharmacy Service

Properly Mark Drugs and Other Similar Products.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/28/2008
Properly Mark Drugs and Other Similar Products.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Quality Care

Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/28/2008
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/29/2008
Make Sure That Each Resident's Nutritional Needs Were Met.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/29/2008
Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Make Sure That Residents Receive Treatment/Services to Continue to Be Able to Care for Themselves, Unless a Change is Unavoidable.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/05/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Make Sure That Residents Receive Treatment/Services to Continue to Be Able to Care for Themselves, Unless a Change is Unavoidable.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/28/2008
Let Residents Give Themselves Their Drugs if They Are Able.
  • Inspection Date: 07/31/2008
  • Correction Date: 08/02/2008
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Provide Services to Meet the Needs and Preferences of Each Resident.
  • Inspection Date: 05/06/2009
  • Correction Date: 06/12/2009
Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care.
  • Inspection Date: 04/15/2010
  • Correction Date: 05/14/2010

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action TakenDateAmount
Civil Money Penalty (CMP)05/06/2009$2,600

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for The Villas at Sunny Acres, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Complaint Filed: 04/11/2011
  • Correction Date: 04/26/2011

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Complaint Filed: 07/31/2008
  • Correction Date: 10/10/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/29/2008
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/28/2008

Resident Assessment

Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/02/2008
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/28/2008
Electronically Record and Report Resident Status Assessments in a Timely Manner As Required in Order to Monitor Resident Health and Progress.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/28/2008

Resident Rights

Provide Services to Meet the Needs and Preferences of Each Resident.
  • Complaint Filed: 07/31/2008
  • Correction Date: 08/28/2008

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that The Villas at Sunny Acres had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 05/17/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/27/2008
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/25/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Building Construction

A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/27/2008
Approved Construction Type or Materials.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/27/2008
A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010
Approved Construction Type or Materials.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Building Service Equipment

Properly Protected Cooking Facilities.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/26/2008
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010
Properly Protected Cooking Facilities.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/25/2010
A Properly Installed and Maintained Dumbwaiter or Escalator.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Corridor Walls and Doors

Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke.
  • Inspection Date: 08/25/2008
  • Correction Date: 09/22/2008
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 08/25/2008
  • Correction Date: 09/22/2008
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/02/2009
Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/25/2010

Electrical

Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/27/2008
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/26/2009
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/15/2009
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Exits and Egress

Exits That Are Accessible at All Times.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/17/2010

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 08/25/2008
  • Correction Date: 08/25/2008
Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/26/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/15/2009

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/26/2009

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/25/2010
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
  • Inspection Date: 08/25/2008
  • Correction Date: 09/26/2008
Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
  • Inspection Date: 06/02/2009
  • Correction Date: 06/25/2009
Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
  • Inspection Date: 05/17/2010
  • Correction Date: 06/16/2010
Source: Medicare Nursing Home Compare; Colorado Department of Public Health and Environment - Retrieved 2011