VILLAS AT SUNNY ACRES, THE

2501 E 104TH AVE
THORNTON, CO, 80233
3032554100
CCN: 065108
4
Overall
3
Health
3
Staffing
5
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
BURNAM, SOONCORPORATE OFFICERNOT APPLICABLE
JORGENSEN, DAVIDCORPORATE OFFICERNOT APPLICABLE
KEETCH, CHADCORPORATE OFFICERNOT APPLICABLE
HORTON, CHRISTOPHEROPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
RAMIREZ SANCHEZ, HUGOOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2024-03-11Fine$20K
Health Deficiencies (30)
2025-04-03 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F761 · 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.
D
F744 · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F678 · 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.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F580 · 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.
2024-03-11 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
G
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
G
F691 · Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
G
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F624 · Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
D
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
D
F600 · 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.
E
F575 · 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.
D
F557 · Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
2023-04-06 · Health
D
F825 · Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
D
F572 · Resident Rights Deficiencies
Give residents a notice of rights, rules, services and charges.
E
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2022-12-05 · Health
E
F744 · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
G
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
E
F600 · 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.
E
F585 · Resident Rights Deficiencies
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.
E
F584 · Resident Rights Deficiencies
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.
D
F578 · Resident Rights Deficiencies
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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.01
3.68
RN Hrs/Resident/Day
0.57
0.54
LPN Hrs/Resident/Day
0.52
0.81
CNA Hrs/Resident/Day
1.91
2.33
PT Hrs/Resident/Day
0.10
0.12
Data as of 2026-03-01