VILLAS AT SUNNY ACRES, THE
Open-data reference.
VILLAS AT SUNNY ACRES, THE is a for profit - corporation facility in THORNTON, CO with 160 certified beds and a 4-star overall CMS rating. The facility has 32 deficiency records on file. Total penalties: $20K.
2501 E 104TH AVE, THORNTON, CO 80233
Phone: 3032554100
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065108
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 160
- Residents
- 145
- In Hospital
- No
- County
- Adams
- Last Inspection
- Apr 3, 2025
Staffing Data
- RN Hours
- 0.57 (nat'l avg: 0.68)
- LPN Hours
- 0.52
- CNA Hours
- 1.91
- Total Nursing Hours
- 3.01 (nat'l avg: 3.89)
- PT Hours
- 0.10
- Nursing Turnover
- 30.3%
- RN Turnover
- 18.8%
What the CMS Record Reveals About VILLAS AT SUNNY ACRES, THE
VILLAS AT SUNNY ACRES, THE operates 160 certified beds in THORNTON, CO with approximately 145 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (3★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 32 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $20K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.01 total nursing hours per resident day (national average 3.89), with RN coverage at 0.57 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, VILLAS AT SUNNY ACRES, THE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 30.3%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (32 most recent)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: May 2, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 2, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: May 2, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: May 2, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: May 2, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: May 2, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 2, 2025
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category: Quality of Life and Care Deficiencies
Corrected: May 2, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: May 2, 2025
Prepare residents for a safe transfer or discharge from the nursing home.
Category: Resident Rights Deficiencies
Corrected: Apr 4, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 4, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 4, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 4, 2024
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 4, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 4, 2024
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 4, 2024
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 4, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 4, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Apr 4, 2024
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category: Resident Rights Deficiencies
Corrected: Apr 4, 2024
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 25, 2023
Give residents a notice of rights, rules, services and charges.
Category: Resident Rights Deficiencies
Corrected: Apr 25, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Apr 25, 2023
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Category: Infection Control Deficiencies
Corrected: Mar 17, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 17, 2023
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 26, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 14.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 12.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 93.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.9% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 18.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 12.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 88.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 23.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 31.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 28.6% | Yes |
Penalty History 1 penalties totaling $20K
| Date | Type | Amount |
|---|---|---|
| Mar 11, 2024 | Fine | $20K |
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Understanding Nursing Home Data
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County Health Data
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Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.