01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-03 | 10 | 2025-04-03 | 6 |
| Cycle 2 | 2024-03-11 | 11 | 2024-03-11 | 5 |
| Cycle 3 | 2022-12-05 | 7 | 2022-12-05 | 0 |
CMS CCN 0651082026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Villas At Sunny Acres, The
2501 E 104Th Ave · Thornton, CO 80233 · Adams County
Certified beds160CMS provider file
Recent citation rows39current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
39 rows in the current release
4 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-08 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Deficient, Provider has date of correction · 2026-05-06 · complaint2025-04-03 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-04-03 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0678Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-05-022025-04-03 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-04-03 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-06-132025-04-03 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-05-312025-04-03 · FIREK0500Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2025-05-052025-04-03 · FIREK0531Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2025-05-212025-04-03 · FIREK0927Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Correction field: Deficient, Provider has date of correction · 2025-06-132024-03-11 · HEALTHF0557Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0575Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0603Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0624Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
Correction field: Deficient, Provider has date of correction · 2024-04-04 · complaint2024-03-11 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-04-042024-03-11 · HEALTHF0691Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-04-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-03-11 | Fine | $19,988 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ENDURA HEALTHCARE LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/21/2016
- THE ENSIGN GROUP INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/01/2017
- HORTON, CHRISTOPHERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/06/2020
- RAMIREZ SANCHEZ, HUGOIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/12/2020
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/21/2016
- JORGENSEN, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2019
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- HORTON, CHRISTOPHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/06/2020
- RAMIREZ SANCHEZ, HUGOIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/12/2020
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/30/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2017
- HORTON, CHRISTOPHERIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/06/2020
- RAMIREZ SANCHEZ, HUGOIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/12/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.06per resident day
RN hours0.58per resident day
Weekend nurse hours2.68per resident day
Staff turnover30.6%CMS reported field
06 / LOCAL RECORDS
Open the Thornton ledger →