Federal inspection record · CMS data as of October 1, 2026
Villas At Sunny Acres, The
2501 E 104th Ave, Thornton, CO · (303) 255-4100
- Cited for abuse (CMS abuse icon)
- Certified beds
- 160
- Residents per day
- 145
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 30, 1969
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Colorado homes
Villas At Sunny Acres, The carries 57 inspection points. That is fewer than 55% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
28 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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G
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
-
G
Provide enough food/fluids to maintain a resident's health.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care9E
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Assist a resident in gaining access to vision and hearing services.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Provide activities to meet all resident's needs.
Resident Rights7E
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
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.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
- E
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.
- E
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.
- D
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.
Freedom from Abuse, Neglect, and Exploitation4E
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Infection Control2D
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Nutrition and Dietary1E
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Pharmacy Service1D
- D
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.
Inspection history
2025-04-03
10 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2024-03-11
11 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2022-12-05
7 health deficiencies · 0 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 52 min of nursing staff time a day, 30 min of it from a registered nurse.
This home
2 h 52 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 33% of nursing staff and 28% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$19,988 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-03-11 | Fine | $19,988 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.8 pts better | 0.6 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.1 pts better | 0.6 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine5 pts worse | 88.4% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.8 pts better | 94.5% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.8 pts better | 2.6% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6.1 pts worse | 14.9% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.4 pts worse | 7.2% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1 pts worse | 12.6% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.2 pts worse | 25.1% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened15 pts worse | 26.7% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased17.7 pts worse | 30.5% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts worse | 1.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.2 pts better | 1.2% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence11.4 pts worse | 32.0% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.2 pts better | 2.2% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.6 pts better | 88.6% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.6 pts better | 11.4% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.1 pts better | 1.5% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine31.2 pts worse | 42.4% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.6 pts better | 18.9% | 20.5% | 23.4% |
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Who owns and runs it
13 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Endura Healthcare LLC | Direct Ownership Interest · Organization | 0% | 2 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Horton, Christopher | Managing Control - Governing Body · Individual | 0% | 17 facilities |
| Horton, Christopher | Operational/Managerial Control · Individual | 0% | 17 facilities |
| Horton, Christopher | Adp Of The SNF · Individual | 0% | 17 facilities |
| Jorgensen, David | Corporate Officer · Individual | 0% | 56 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Ramirez Sanchez, Hugo | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Ramirez Sanchez, Hugo | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ramirez Sanchez, Hugo | Adp Of The SNF · Individual | 0% | 1 facilities |
| The Ensign Group Inc | Indirect Ownership Interest · Organization | 0% | 135 facilities |
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Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Install corridor and hallway doors that block smoke.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Services3E
- D
Meet other general requirements that are deficient.
- D
Have elevators that firefighters can control in the event of a fire.
- E
Install properly constructed and protected linen or trash chutes.
Egress2F
- E
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.
- F
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 Systems2F
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Have power receptacles that are properly grounded.
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Other homes nearby
-
Thornton Care Center
Thornton, CO · Long Peak Operating Company
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 9 min
- Fines
- $21,483
-
Malley Transitional Care Center
Northglenn, CO · The Ensign Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 10 min
- Fines
- $14,380
-
Skylake Post Acute
Thornton, CO · Pacs Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 56 min
- Fines
- $56,224