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
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
0.52
Licensed practical nurse staffing
Aide hours / resident day
1.91
Nurse aide staffing
Weekend hours
2.53
Weekend nurse staffing
RN turnover
19%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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