Cycle 1
Health 2025-04-03 · Fire 2025-04-03
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Thornton, CO
Villas At Sunny Acres, The
4-star overall rating with 3-star inspections with $19,988 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2501 E 104th Ave, Thornton, CO
(303) 255-4100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
145
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1969-12-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.53
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,490
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.27
Baseline 16.08% · Performance 20.38% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Healthcare-associated infections
4.59
Baseline 6.81% · Performance 6.46% · Measure score 4.59 · Achievement 4.59 · Improvement 1.40
Total nurse turnover
6.23
Baseline 53.23% · Performance 38.21% · Measure score 6.23 · Achievement 6.23 · Improvement 4.79
Adjusted total nurse staffing
1.32
Baseline 3.57 hours · Performance 3.45 hours · Measure score 1.32 · Achievement 1.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 4.96% · Lower 95% interval 6.27% |
| Discharge to community | 52.89% |
50.57%
2.3 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 51.35% · Lower 95% interval 44.65% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 88% |
95.27%
7.3 pts worse
|
Numerator 66 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 34 · Denominator 58 |
| Discharge mobility score | 46.55% |
50.94%
4.4 pts worse
|
Numerator 27 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.46% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 2.09% |
8.2%
6.1 pts worse
|
Numerator 5 · Denominator 239 |
| Staff flu vaccination coverage | 89.77% |
42%
47.8 pts better
|
Numerator 272 · Denominator 303 |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 32 · Denominator 58 |
| Transfer of health information to provider | 60.87% |
95.95%
35.1 pts worse
|
Numerator 14 · Denominator 23 |
| Transfer of health information to patient | 78.13% |
96.28%
18.2 pts worse
|
Numerator 25 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 35% |
25.2%
9.8 pts better
|
Numerator 14 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.7
1.3 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
93.5%
0.2 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 89.3% · Q4 85.2% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
94.7%
6.5 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.6% · Q3 1.6% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.0% |
7.4%
4.6 pts worse
|
11.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.6% · Q3 10.0% · Q4 16.4% · 4Q avg 12.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 9.7% · Q3 8.0% · Q4 5.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
11.2%
1.5 pts worse
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 14.2% · Q3 10.6% · Q4 11.9% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.6% |
20.6%
8 pts worse
|
16.7%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 28.0% · Q3 27.4% · Q4 29.4% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.3% |
15.2%
3.1 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 18.9% · Q3 18.8% · Q4 26.0% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
14.6%
About the same
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 13.6% · Q3 12.7% · Q4 23.1% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
22.4%
9 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 38.7% · Q3 26.1% · Q4 36.8% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.8% · Q4 1.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
76.4%
22.5 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 98.6% · Q4 98.4% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.8%
4.8 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 9.1% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.6% |
75.6%
52 pts worse
|
79.7%
56.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.7% |
20.3%
6.6 pts better
|
23.9%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 16.4% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-11 · Fire 2024-03-11
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-05 · Fire 2022-12-05
10 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-04-03
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-04-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-04-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-03
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-03
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-06-13
F · Potential for more than minimal harm
2024-03-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-03-11
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-03-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-03-11
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
G · Actual harm
2024-03-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-04
G · Actual harm
2024-03-11
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-04-04
G · Actual harm
2024-03-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-04
E · Potential for more than minimal harm
2024-03-11
F575 · Resident Rights Deficiencies
Health
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.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-04
E · Potential for more than minimal harm
2023-04-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-06
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-06
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-04-25
G · Actual harm
2022-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-12-05
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-12-05
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-12-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-12-05
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-12-26
Penalties and ownership
What sits behind the stars
$19,988
2024-03-11
Fine
Fine · fine $19,988
Fine
Ownership
Burnam, Soon
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Ramirez Sanchez, Hugo
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Thornton Care Center
Thornton, CO
2-star overall rating with 1-star inspections with abuse icon flag with $21,483 in total fines with 25 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Malley Transitional Care Center
Northglenn, CO
3-star overall rating with 2-star inspections with $32,003 in total fines with 6 recent health deficiencies
#3
Skylake Post Acute
Thornton, CO
2-star overall rating with 2-star inspections with $25,572 in total fines with 11 recent health deficiencies
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