Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villas At Sunny Acres, The during CMS and state inspections, most recent first.
A resident with osteoporosis, vertebral fractures, and chronic pain had a PRN oxycodone order and reported generally receiving the medication when requested, but recalled being told once that none was available. Facility policies prohibited exploitation and drug diversion, yet an LPN entered the building on a day off, participated in a narcotic count with an RN, and later admitted to taking the resident’s oxycodone card from the medication cart. The oncoming LPN then counted narcotics alone, found a discrepancy, altered the narcotic count sheet without notifying anyone, and only discovered the card missing when the resident requested PRN oxycodone, at which point oxycodone was obtained from the emergency supply and the discrepancy was reported to the DON.
Surveyors found that the facility did not consistently serve palatable or properly prepared food, with test trays revealing dry, flavorless chicken and Hawaiian rice missing key ingredients. Multiple residents reported dissatisfaction with food quality, variety, and temperature, while staff interviews confirmed deviations from recipes and uncommunicated menu substitutions.
A resident's representative was not promptly notified of a fall, subsequent medical imaging, new pain medication orders, and a diagnostic imaging appointment. The facility attempted to contact a deceased family member instead of the listed representative, resulting in a delay of approximately 17 hours before the correct party was informed. Documentation and staff interviews confirmed that the notification did not occur as required by facility policy.
Two dependent residents did not receive required assistance with repositioning and incontinence care, as observations showed one remained in bed and another in a wheelchair for several hours without being repositioned or offered toileting help, despite care plans and staff interviews confirming the need for two-hourly checks.
A resident's resuscitation preferences were not properly documented in the EMR or care plan, and the required MOST form was not signed by a physician or available in the designated binder at the time of review. This resulted in the absence of a clear physician order for CPR status and incomplete documentation of advance directives.
A resident with dementia and a high risk for wandering was able to leave a secured unit unsupervised when both the nurse and CNA were absent from the unit, and a door was not properly latched. The care plan did not address the resident's elopement risk prior to the incident, and observations showed that secure unit doors could be opened without a key card, contributing to the resident's ability to exit and sustain minor injuries.
A resident with end-stage renal disease and multiple comorbidities did not have consistent or thorough documentation of dialysis treatments, as required by facility policy. Several dialysis communication forms and medication administration records were incomplete or missing, with no explanation in the medical record. Staff interviews confirmed gaps in documentation, and facility leadership was unaware of the missing information.
A resident with dementia did not receive individualized, person-centered care as staff failed to consistently implement or document meaningful interventions to address behavioral symptoms. Despite care plans outlining specific activities and preferences, staff did not offer or facilitate these interventions during observed periods, nor did they document attempts to redirect the resident using care-planned strategies.
A resident was found with lidocaine cream and diclofenac gel at their bedside, neither of which had a physician's order or documentation authorizing self-administration. Staff confirmed that medications should not be left at the bedside without proper assessment, and the facility's policy restricts medication access to authorized personnel only.
Staff did not consistently wear required gowns, in addition to gloves, when providing incontinence care to two residents on enhanced barrier precautions for pressure wounds. Despite clear signage and available PPE, CNAs provided care without gowns, contrary to CDC guidance and facility policy. Staff interviews confirmed knowledge of the requirements but revealed lapses in protocol adherence.
Misappropriation of Resident Narcotic Medication Due to Drug Diversion and Improper Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a narcotic medication card containing 89 oxycodone tablets was taken from the medication cart. Facility policies on Abuse Prevention and Reporting and Drug Diversion Reporting and Response defined exploitation and drug diversion, including misappropriation of residents’ property and unauthorized taking of prescription medications. Despite these policies, a nurse accessed the building on a day off, participated in a narcotic count, and subsequently removed a resident’s oxycodone card from the cart without authorization. The affected resident was an older adult with diagnoses including muscle wasting and atrophy, age-related osteoporosis, wedge compression fractures of the T11–T12 vertebrae, and muscle weakness. The resident was cognitively intact with a BIMS score of 15/15 and had PRN oxycodone 5 mg ordered every 8 hours as needed for pain. The resident reported daily pain managed with scheduled medication and occasional PRN oxycodone, and recalled being told on one occasion that there was no oxycodone available in the building, which he found unusual because he did not request it frequently. Record review showed that the resident had received PRN oxycodone for pain rated 7/10 on a date shortly before the medication card was discovered missing. Events leading to the deficiency included multiple deviations from narcotic control procedures. On the day the card was taken, the offgoing RN completed the narcotic count with an LPN who was not scheduled to work that day, and documented 24 narcotic cards on the count sheet, although that LPN did not sign the sheet. The oncoming LPN later counted narcotic cards alone, identified a discrepancy between the actual number of cards and the number documented, and unilaterally altered the narcotic count sheet without notifying anyone. When the resident later requested PRN oxycodone, this oncoming LPN could not locate the resident’s oxycodone card in the cart and instead obtained oxycodone from the emergency supply, then reported the discrepancy to the DON. Subsequent investigation and staff statements documented that the off-duty LPN admitted to taking the resident’s oxycodone medication card from the cart on the earlier date.
Failure to Consistently Serve Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to consistently serve food that was palatable in taste and texture, as required by its own policy and procedure. During a survey, a test tray evaluation revealed that the chicken was dry and flavorless, and the Hawaiian rice tasted like plain rice and did not contain pineapple, despite the recipe specifying pineapple tidbits as an ingredient. Additionally, the posted menu indicated sugar snap peas were to be served, but green peas were provided instead. Resident interviews indicated dissatisfaction with the food, citing issues such as lack of variety, food being too salty or tasteless, food being too spicy, poor quality, and food being served cold or not looking appetizing. Resident council meeting minutes also documented ongoing complaints about cold food and limited variety. Staff interviews revealed deviations from recipes and menu substitutions without proper communication or menu updates. One cook omitted pineapple from the Hawaiian rice, and another used different ingredients for the orange-glazed chicken than those specified in the recipe. The dietary manager acknowledged running out of chicken thighs and substituting chicken breasts, which affected the quality of the dish. The dietary manager also admitted to not serving sugar snap peas due to distributor issues and not updating the posted menu accordingly. These actions and inactions led to the deficiency in providing palatable, attractive, and appropriately prepared food to residents.
Failure to Timely Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify a resident's representative of significant changes in the resident's condition, including a fall, the need for medical imaging, new pain medication orders, and a diagnostic imaging appointment. According to the facility's policy, the responsible party must be notified of any change in the resident's condition, and all attempts to reach the physician and responsible party should be documented, including the time and response. However, documentation and interviews revealed that the resident's representative was not promptly informed of these events. The resident involved was an 89-year-old with multiple diagnoses, including atrial fibrillation, heart failure, a history of TIA, and cognitive communication deficits. The resident had moderate cognitive impairment and was dependent on her representative for communication regarding her care. The representative was listed as the first emergency contact, and there was no power of attorney on file. Despite this, the facility attempted to contact the resident's deceased daughter, who was not listed as a contact, and failed to notify the actual representative in a timely manner. Progress notes indicated that the fall occurred late at night, and while there were attempts to notify a family member, these were directed to the wrong individual. The resident's representative was not informed of the fall, the Xray, or the new pain medication orders until approximately 17 hours after the incident, and only after he inquired about the resident's condition. Staff interviews confirmed that the expectation was to notify the responsible party after a fall, but this did not occur as required by facility policy.
Failure to Provide Timely Repositioning and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two dependent residents, resulting in deficiencies related to nutrition, grooming, personal, and oral hygiene. Observations over a four-hour period revealed that one resident remained in bed, leaning to one side, and another resident remained in a wheelchair, both without being repositioned or offered incontinence care as required. The room was noted to have a persistent urine odor, and one resident's brief was found to be saturated with urine after more than three hours without care. Resident #326, an 87-year-old with muscle weakness, disabilities, and a urinary tract infection, was documented as requiring substantial assistance with toileting and personal hygiene. Her care plan specified the need for staff assistance with toileting and repositioning every two hours to facilitate lung secretion movement and drainage. Despite these documented needs, staff did not provide timely toileting assistance or repositioning, as evidenced by the extended period without care and the saturated brief. Resident #8, an 85-year-old with dementia, lack of coordination, and difficulty walking, was also dependent on staff for transfers, toileting, and repositioning. Her care plan required staff assistance for repositioning, but she was observed sitting in her wheelchair for four hours without being repositioned. Staff interviews confirmed that both residents should have been checked and repositioned every two hours, but this standard of care was not met during the observed period.
Failure to Document Resident CPR Status and Advance Directives in Medical Record
Penalty
Summary
The facility failed to accurately document a resident's resuscitation choices in the medical record, as required by its Advanced Directive policy. Specifically, there was no physician's order in the electronic medical record (EMR) indicating the resident's wishes regarding cardiopulmonary resuscitation (CPR). Additionally, the resident's comprehensive care plan did not include documentation of the resident's CPR preferences. The medical orders for scope of treatment (MOST) form was not available in the EMR or the Advanced Directive binder at the time of review, and had not been signed by the physician prior to the survey. The resident involved was a 73-year-old individual admitted with diagnoses including esophageal obstruction, lobar pneumonia, and asthma, and was assessed as cognitively intact. Staff interviews revealed that the process for handling MOST forms involved the admitting nurse completing the form and confirming the order in the EMR, with the original form awaiting provider signature before being scanned into the EMR. However, in this case, the MOST form was found unsigned in a folder and was not accessible in the EMR or binder until after the survey began, resulting in a lack of clear documentation of the resident's resuscitation wishes.
Failure to Prevent Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia and a documented high risk for wandering and elopement was able to leave a secured unit without proper supervision. The resident had a history of wandering, exit-seeking, and behaviors such as pacing, attempting to open doors, and triggering alarms. Despite these behaviors being documented in the medical record and elopement/wandering assessments, the resident's care plan did not address wandering or elopement risks until after the incident was discovered during a survey. On the night of the incident, the unit nurse was attending to another resident on a different unit, and the CNA assigned to the resident's unit was on break, leaving the unit unsupervised. During this time, the resident managed to jump over the nurse's station, access a neighboring unit, and exit through a door that was not properly latched. The resident was later found outside near the facility's entrance and sustained multiple minor injuries, including lacerations to the forehead, foot, and knee. Observations during the survey revealed that doors to the secure unit could be opened without a key card, and the locking mechanisms were not consistently functioning as intended. Staff interviews confirmed that there were lapses in ensuring continuous supervision during staff breaks and that the care plan had not been updated to reflect the resident's elopement risk prior to the incident.
Incomplete Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received care consistent with professional standards of practice. Specifically, the facility did not consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center, nor did it ensure thorough documentation of the resident's dialysis treatments. The facility's policy required licensed nurses to complete baseline, pre-, and post-dialysis sections of the communication record, while the dialysis center was responsible for its own section. However, multiple communication forms were incomplete or missing, and there was no documentation explaining these omissions. The resident involved was an 80-year-old individual with end-stage renal disease, a history of kidney removal due to malignancy, dementia, and Melkersson's syndrome, among other diagnoses. The resident required substantial assistance with daily activities and received dialysis three times a week. The care plan included interventions such as monitoring the arteriovenous fistula, encouraging attendance at dialysis, and monitoring labs, but did not specify monitoring vital signs and weights pre- and post-dialysis. Physician orders included regular dialysis, vital sign checks upon return, and monitoring the port site for infection. Record reviews revealed that several dates on the medication administration record (MAR) and dialysis communication forms were left blank without explanation, and some communication forms were missing entirely. Staff interviews confirmed that nurses were responsible for documenting pre- and post-dialysis information, but they were unsure why documentation was incomplete. Facility leadership was unaware of the missing information in both the communication forms and the MAR for the resident.
Failure to Provide Person-Centered Dementia Care and Meaningful Interventions
Penalty
Summary
The facility failed to provide appropriate, person-centered treatment and services to a resident diagnosed with dementia, resulting in a deficiency related to the resident's physical, mental, and psychosocial well-being. The resident, an 83-year-old with dementia, type 2 diabetes, and insomnia, exhibited significant cognitive impairment, including severe memory problems and impaired decision-making. The resident required partial to moderate assistance with most activities of daily living and was noted to value music, group activities, going outside, and religious participation. Despite these preferences, staff did not consistently offer or facilitate meaningful activities or interventions tailored to the resident's needs during observed periods. Multiple observations revealed that staff failed to redirect the resident with individualized or meaningful activities when he engaged in behaviors such as wandering, moving furniture, attempting to urinate in inappropriate places, and interacting inappropriately with other residents. Staff often responded by verbally redirecting the resident or simply telling him about upcoming activities, such as a church group, but did not physically assist or encourage his participation. Additionally, when the resident displayed behaviors like moving furniture or attempting to use another resident's bathroom, staff did not offer alternative activities or assist him to his own room, missing opportunities to address his needs in a person-centered manner. Record reviews and staff interviews further indicated that while care plans included interventions such as offering coffee, snacks, walks, crafts, and sensory activities, there was a lack of documentation and evidence that these interventions were consistently attempted or implemented. Behavior and nursing notes frequently failed to specify what redirection strategies were used, if any, and did not reflect the use of care-planned interventions. Staff interviews confirmed that although new interventions were identified, such as a fidget lock box and fake tools, these were not observed being offered to the resident during the survey period. The facility also did not document or incorporate the resident's long-standing preference for sleeping on the floor as a potential intervention, despite being informed by the resident's representative.
Unsecured and Unordered Medications Left at Bedside
Penalty
Summary
Facility staff failed to ensure that all drugs and biologics were properly stored and labeled, as required by facility policy and professional standards. During an interview and observation, a white rectangular box labeled lidocaine hydrochloride 3% cream was found on a resident's bedside table, along with a used tube of the same medication. The resident stated that staff applied the cream during personal care. Further investigation by a registered nurse revealed that both the lidocaine cream and diclofenac 3% gel were present at the bedside, but there were no corresponding physician orders for these medications in the resident's electronic medical record. Additionally, there was no documentation indicating that the resident was assessed or authorized to self-administer medications. Staff interviews confirmed that medications should not be left at a resident's bedside unless a self-administration assessment has been completed and approved. The registered nurse and the director of nursing both stated that the resident in question did not have such an assessment, and neither medication should have been accessible at the bedside. The nurse also confirmed that he had not administered either medication and was unsure which staff member had done so. The facility's policy clearly restricts medication access to licensed personnel or those lawfully authorized, and this protocol was not followed in this instance.
Failure to Adhere to Enhanced Barrier Precautions for Residents with Pressure Wounds
Penalty
Summary
The facility failed to ensure that staff consistently followed infection prevention and control protocols, specifically regarding the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) due to pressure wounds. Observations revealed that, despite clear signage and the availability of PPE, staff did not wear protective gowns while providing incontinence care to two residents who were on EBP. In both cases, staff wore gloves but omitted gowns, which was contrary to both CDC guidance and the facility's own infection control policy. For one resident with pressure wounds on the thigh and coccyx, two certified nurse aides (CNAs) provided incontinence care using gloves but did not don gowns as required. Similarly, another resident with pressure wounds on both heels received incontinence care from a CNA who also wore gloves but failed to use a gown. Both residents had clear signage on their doors indicating the need for gloves and gowns during high-contact care activities, and PPE was readily accessible in their rooms. Interviews with staff, including CNAs, an RN, an LPN, the DON, and the infection preventionist, confirmed that staff were aware of the EBP requirements and the importance of using both gloves and gowns for residents on EBP. However, there was uncertainty among some staff regarding which residents were on EBP and lapses in adherence to the protocol, as evidenced by the observed failures to use gowns during resident care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Thornton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thornton Care Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Malley Transitional Care Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Skylake Post Acute | 2.4 mi | ★★★★★ | 15 | 1 |
| Center At Northridge, Llc, The | 3.1 mi | ★★★★★ | 0 | 0 |
| Irondale Post Acute | 4.9 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.