Villas at Sunny Acres, the
2501 E 104th Ave, Thornton, CO 80233
Villas at Sunny Acres, the is a nursing home in Thornton, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (303) 255-4100
- Last standard health inspection
- April 3, 2025 (1 year ago)
- Certified beds
- 160
- Residents per day, on average
- 145.4
- Ownership type
- For profit - Corporation
- Legal business name
- Sunny Acres Healthcare LLC
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
More health citations than the Colorado average (28 vs 25).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of June 24, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on April 8, 2026
CMS lists this as a complaint inspection.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on May 6, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Fire safety citation
CMS changed citation K0363 from severity F to D. It is from the fire safety inspection on May 2, 2025. Severity D: potential for more than minimal harm, isolated.
Fire safety citation
CMS removed citation K0324 from the fire safety inspection on May 2, 2025.
Fire safety citation
CMS removed citation K0353 from the fire safety inspection on May 2, 2025.
Fire safety citation
CMS removed citation K0711 from the fire safety inspection on May 2, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
9 citations
Health inspection on April 3, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on May 2, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on May 2, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 2, 2025.
Citation F0678. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on May 2, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0689 3 times since 2022.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 2, 2025.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0744 2 times since 2022.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 2, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0880 2 times since 2024.
6 citations
Fire safety inspection on April 3, 2025
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 13, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 31, 2025.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 31, 2025.
Citation K0500. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on May 5, 2025.
Citation K0531. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
CMS lists it as corrected on May 21, 2025.
Citation K0927. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on June 13, 2025.
CMS update of August 29, 2024
Fine
CMS changed the fine from March 11, 2024 from $30,750 to $19,988.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
11 citations
Health inspection on March 11, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
65 of 210 Colorado homes (31%) got a citation at the actual harm level in 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 4, 2024.
Citation F0691. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on April 4, 2024.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 4, 2024.
Citation F0575. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 4, 2024.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on April 4, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 4, 2024.
CMS has cited this home for F0600 2 times since 2022.
Citation F0603. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS lists it as corrected on April 4, 2024.
Citation F0624. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prepare residents for a safe transfer or discharge from the nursing home.
CMS lists it as corrected on April 4, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on April 4, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 4, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 4, 2024.
5 citations
Fire safety inspection on March 11, 2024
CMS lists this as a standard inspection.
Citation K0223. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on May 31, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 12, 2024.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on May 31, 2024.
Citation K0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on May 31, 2024.
Citation K0541. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on May 31, 2024.
Fine
March 11, 2024 (2 years ago)
CMS fine of $19,988 on March 11, 2024.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
7 citations
Health inspection on December 5, 2022
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
45 of 210 Colorado homes (21%) got a citation at the actual harm level in 2022.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 26, 2022.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 26, 2022.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 26, 2022.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 26, 2022.
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on December 26, 2022.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 26, 2022.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on December 26, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ENDURA HEALTHCARE LLCDirect ownership interest · not applicable · since 12/21/2016
- THE ENSIGN GROUP INCIndirect ownership interest · not applicable · since 07/01/2017
- HORTON, CHRISTOPHEROperational/managerial control · not applicable · since 10/06/2020
- RAMIREZ SANCHEZ, HUGOOperational/managerial control · not applicable · since 06/12/2020
Questions
When was Villas at Sunny Acres, the last inspected?
CMS lists April 3, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Villas at Sunny Acres, the have?
CMS lists 28 health citations since December 5, 2022. CMS also calls these deficiencies.
Has Villas at Sunny Acres, the been fined?
CMS lists 1 fine in the past three years, $19,988 in total.
What is the CMS star rating of Villas at Sunny Acres, the?
Its CMS overall star rating is 2 of 5.
Is Villas at Sunny Acres, the a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.