Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
VILLAS AT SUNNY ACRES, THE
THORNTON, CO · 160 certified beds · Last Life Safety survey April 3, 2025
CMS Certification Number 065108 · first certified December 1969
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
11 citations — more than 32% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to April 2027. This facility’s last Life Safety survey was April 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 5, 2022 | 0 |
| March 11, 2024 | 5 |
| April 3, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2025-04-03 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-03-11 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2024-03-11 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2025-04-03 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 1 | 2025-04-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-04-03 |
| K-0222 | 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. | 1 | 2025-04-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-04-03 |
What the citations cover
- Smoke Deficiencies 4
- Services Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 3, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (May 31, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 13, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 31, 2025) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (May 5, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (May 21, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (June 13, 2025) |
March 11, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (September 12, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Waiver has been granted (May 31, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 31, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (May 31, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.