VILLAS AT SUNNY ACRES, THE

An administrative relicensure survey was completed on 5/14/26. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A). Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B). A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (E). A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (G). A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.

A relicensure survey with complaints revisit was completed on 8/26/25 for all previous deficiencies cited on 5/20/25. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event RYW511 were cited prior to the regulation revision that was implemented on 7/1/25.

A recertification survey with complaints revisit was completed on 8/26/25 for the previous deficiency cited on 5/20/25. The residence is in compliance with all regulations surveyed. The deficiency cited for Event ZRI111 was cited prior to the regulation revision that was implemented on 8/14/25.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey with complaints #CO35403, #CO37337, #CO37789, #CO38753 was completed on 5/20/25. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to have sufficient ventilation to meet the needs of seven current residents (#2, #7, #9-#13). (Cross-reference T2810)Findings include:On 5/20/25, during the onsite survey, areas of the residence were above 76 degrees Fahrenheit (F), and limited ventilation was circulating as follows: At 10:46 a.m., Resident #10's room was 83 degrees F.At 10:48 a.m., the hallway was 81 degrees F within approximately one foot of a portable air conditioning (AC) unit. At 10:49 a.m., the activity room was approximately 81 degrees, three feet from the AC vent. Heating, ventilation, and air conditioning (HVAC) documents, dated 5/5/25 and 5/14/25, read in part that an HVAC company provided the residence with invoices to repair the AC unit. On 5/10/25 through 5/14/25, written grievances by Residents #2, #7, and #11-#13 read in part that the residents' rooms were uncomfortably hot due to the disrepair of the central AC. The residence staff and residents signed that the grievances were resolved on 5/19/25. On 5/19/25 and 5/20/25, during the onsite survey, Residents #2, #7, and #9-#13 stated that they were uncomfortably hot in their rooms when the residence's central AC was not working beginning on approximately 5/10/25 until 5/18/25. Residents #2, #7, #9, and #11-#13 added that the residence provided portable AC units on 5/18/25 or 5/19/25, and that resolved their discomfort. Resident #10 stated that she had not received a portable AC unit, and despite the repair to the air conditioning on 5/19/25, her room remained too warm for her comfort. Residents #7 and #10 reported that the residence did not provide them with fans for ventilation. Residents #7 and #10 stated they provided fans; however, the ventilation was not adequate. Residents #2, #7, #9, and #10 were hesitant to leave their doors open as the residence had experienced recurring infestations of bed bugs. On 5/20/25 at 11:09 a.m., the director of maintenance (DOM) stated that the residence's central AC initially stopped working approximately three weeks prior to the onsite survey, was repaired immediately, and was not operational again about ten days prior to the onsite survey. He added that the residence provided some portable AC units to residents in their rooms and the hallway; however, the residence did not provide each resident with a unit. He added that the central AC was repaired on 5/19/25 with a temporary, used motor until the residence received a permanent option. On 5/20/25 at 1:16 p.m., the administrator stated that several residents submitted written grievances regarding the lack of AC and their discomfort. She added that the residence had a limited number of portable AC units, placed them in the hallways, and provided them to residents who had difficulty breathing or who filed a grievance. She added that in the future, she would ask to rent enough AC units for each resident in order to ensure they were comfortable and safe. She stated she was not aware that the central AC was repaired with a temporary motor. She added that she worked during the period the AC was out, and it became uncomfortably hot in the residence. On 5/20/25 at approximately 2:00 p.m., the sister facility administrator stated the residence had access to 30 portable AC units. On 5/20/25, the residence had 35 resident rooms, 34 of which were occupied by residents.

Based on observation, record review and interview, the residence failed to have an effective pest control policy to ensure eradication of pests including bed bugs, affecting 35 residents. (Cross-reference T2620)Specifically, the residence had a history of bed bug infestations. During the onsite survey, the residence failed to have an effective pest control policy and as a result the bed bug infestation continued. Residents #2, #6, #7, #9, and #10 reported ongoing fear and anxiety related to the risk of ongoing bed bug infestations at the residence. As a result, the residents kept the doors to their rooms closed despite relying on portable air conditioners in the hallway while the central air conditioning was not operating. Finding include:1. Residence PolicyThe residence's August 2021 Infection Control policy read in part that the residence provided an environment that was free of pests. 2. ObservationsOn 5/19/25 at 8:28 a.m., a white powder was on the floor outside the door leading into Resident #2's bedroom. On 5/19/25 at 10:41 a.m., bed bugs crawled on Resident #6's bed. On 5/20/25 at 10:40 a.m., several insects that were consistent in the shape and size of bed bugs were smeared on the common bathroom door. On 5/20/25 at approximately 10:45 a.m., a bed bug crawled on Resident #7's jacket while he was wearing it. On 5/20/25 at 12:04 p.m., three bed bug smears were on the wall and baseboards of the activity room. 3. Record ReviewThe residence's billing contract with an external pest control company, dated 7/8/24, read in part that the pest control company did not provide routine inspections or treatment for bed bugs at the residence. However, the company provided services as needed for a $400 charge. The residence's contracted pest control billing documents, dated 7/3/24 to 5/16/25, read in part as follows:On 7/3/24, bed buds in a resident roomOn 8/2/24, insects and spiders were reported in resident's roomsOn 9/24/24, live activity of bed bugsOn 2/18/25, live activity of bed bugsOn 3/6/25, live activity of bed bugsOn 3/20/25, live activity of bed bugs in residenceOn 5/16/25, bed bugs in resident's roomsA progress note, dated 8/24/24, read in part that a staff member noticed that the Resident #5's right eye was red and a bit swollen. The resident stated it was due to the removal of bed bugs in his eye at the hospital. 4. InterviewsOn 5/19/25 at approximately 7:30 a.m., Staff #1 stated that the residence found bed bugs one week prior to the on site investigation in three different rooms, and Resident #1 had them during the onsite survey. On 5/19/25 at 8:28 a.m., Resident #2 stated that she put a white powder on the floor leading into her bedroom to keep bed bugs from coming into her room. She expressed that she felt extremely anxious about bed bugs coming into her room. Resident #2 stated that she kept her own bottle of bed bug spray in her room, due to the residence having bed bugs. On 5/19/25 at 10:35 a.m., Resident #6 stated that her friend down the hallway had bed bugs and she was worried that she would get them. She stated that this caused her to have anxiety and it was affecting her sleep. She had concerns that she might have bed bugs because she had been itchy. On 5/19/25 at 11:03 a.m., the administrator stated the residence recently found bed bugs in Resident #1's room, and the pest control company came out. She added that there had been other infestations in January and March 2025, and periodically over the last three years. She stated that residents were upset about the presence of bed bugs within the residence, and Resident #2 had placed an anti-bed bug powder in front of the door of her room. In a later interview, on 5/20/25 at approximately 1:20 p.m., she stated that the pest control company sprayed for bed bugs when requested and did not conduct routine inspections. She affirmed that routine inspections by the pest control company would have been a proactive intervention. At approximately 2:15 p.m., she stated that current residents had bed bugs present in their rooms, and that the residence had difficulty addressing the bed bug infestation with Resident #8 as he would not allow staff to launder his items or assist with a shower. She added that Resident #8 walked around the residence wearing untreated clothing. She stated that the residents were often worried they would get bed bugs and that worry was harmful to them. On 5/19/25 at 3:10 p.m., a sister facility administrator stated that Resident #6 did not want to come out of her room because she had bed bugs. She also stated that Resident #6 was upset because she did not want her family to find out that she had bed bugs. On 5/20/25 at 10:44 a.m., Resident #10 stated that the residence had recurring bed bug infestations. She added she had not had an infestation in her room, but was often anxious about getting an infestation since they were so common. On 5/20/25 at 10:45 a.m., Resident #7 stated that he was scared that he would get bed bugs because other residents currently had them. On 5/20/25 at 10:50 a.m., Staff #3 stated that she had witnessed bed bugs crawling on residents' clothes. Furthermore, she had also seen other insects crawling on residents' clothing and furniture. On 5/20/25 at 10:53 a.m., Resident #9 stated that a few months prior to the onsite visit, the residence found an insect that appeared to be a bed bug in her room. The residence isolated her in another room; she had no access to most of her clothing and no shoes until the pest control company sprayed her room four days later. She added that since then, she had found anything that resembled a bed bug, and she felt anxious and worried that she had an infestation and would have to go through the difficulty of isolation again. On 5/20/25 at 11:09 a.m., the director of maintenance (DOM) stated that bed bug infestations had been a problem at the residence for at least one year. He stated the pest control company came out and sprayed when the residence found a bed bug. He added that the residence had not tried other methods, such as heat treatment, and had not had the company complete routine inspections to mitigate the infestations of bed bugs. He added that it would have been proactive for the residence to have had the pest control company routinely inspect for bed bugs.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.20 The assisted living residence shall provide all residents with regular opportunities to participate in structured engagement and shall support the pursuit of each resident's interests. 22.8 There shall be a sufficient supply of hot water during peak usage demand.

A recertification survey with complaints #CO35404, #CO38754 was completed on 5/20/25. A deficiency was cited.

Based on observation, interview and record review the facility (residence) failed to maintain a comfortable temperature throughout the residence and members' (residents') rooms, sufficient to accommodate the use and needs of the residents, never to fall outside the range of 68 degrees to 76 degrees Fahrenheit (F), affecting seven current residents (#2, #7, #9-#13). Findings include:On 5/20/25, during the onsite survey, areas of the residence were above 76 degrees Fahrenheit (F), and limited ventilation was circulating as follows: At 10:46 a.m., Resident #10's room was 83 degrees F.At 10:48 a.m., the hallway was 81 degrees F within approximately one foot of a portable air conditioning (AC) unit. At 10:49 a.m., the activity room was approximately 81 degrees, three feet from the AC vent. Heating, ventilation, and air conditioning (HVAC) documents, dated 5/5/25 and 5/14/25, read in part that an HVAC company provided the residence with invoices to repair the AC unit. On 5/10/25 through 5/14/25, written grievances by Residents #2, #7, and #11-#13 read in part that the residents' rooms were uncomfortably hot due to the disrepair of the central AC. The residence staff and residents signed that the grievances were resolved on 5/19/25. On 5/19/25 and 5/20/25, during the onsite survey, Residents #2, #7, and #9-#13 stated that they were uncomfortably hot in their rooms when the residence's central AC was not working beginning on approximately 5/10/25 until 5/18/25. Residents #2, #7, #9, and #11-#13 added that the residence provided portable AC units on 5/18/25 or 5/19/25, and that resolved their discomfort. Resident #10 stated that she had not received a portable AC unit, and despite the repair to the air conditioning on 5/19/25, her room remained too warm for her comfort. Residents #7 and #10 reported that the residence did not provide them with fans for ventilation. Residents #7 and #10 stated they provided fans; however, the ventilation was not adequate. Residents #2, #7, #9, and #10 were hesitant to leave their doors open as the residence had experienced recurring infestations of bed bugs. On 5/20/25 at 11:09 a.m., the director of maintenance (DOM) stated that the residence's central AC initially stopped working approximately three weeks prior to the onsite survey, was repaired immediately, and was not operational again about ten days prior to the onsite survey. He added that the residence provided some portable AC units to residents in their rooms and the hallway; however, the residence did not provide each resident with a unit. He added that the central AC was repaired on 5/19/25 with a temporary, used motor until the residence received a permanent option. On 5/20/25 at 1:16 p.m., the administrator stated that several residents submitted written grievances regarding the lack of AC and their discomfort. She added that the residence had a limited number of portable AC units, placed them in the hallways, and provided them to residents who had difficulty breathing or who filed a grievance. She added that in the future, she would ask to rent enough AC units for each resident in order to ensure they were comfortable and safe. She stated she was not aware that the central AC was repaired with a temporary motor. She added that she worked during the period the AC was out, and it became uncomfortably hot in the residence. On 5/20/25 at approximately 2:00 p.m., the sister facility administrator stated the residence had access to 30 portable AC units. On 5/20/25, the residence had 35 resident rooms, 34 of which were occupied by residents.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10.8.7505. F.2 Member EngagementIn consultation with Members served, Alternative Care Facility Provider Agencies shall provide social and recreational engagement opportunities both within and outside the setting.