Cycle 1
Health 2024-01-11 · Fire 2024-01-11
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Denver, CO
Suites At Clermont Park Care Center, The
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2480 S Clermont St, Denver, CO
(720) 974-3700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
4.66
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
948
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0168
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.82% · Performance 17.00% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 4.98% · Performance 4.91% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
0
Performance 66.10% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.73
Baseline 4.27 hours · Performance 4.42 hours · Measure score 4.73 · Achievement 4.73 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 7.83% · Lower 95% interval 7.18% |
| Discharge to community | 72.85% |
50.57%
22.3 pts better
|
Better than the National Rate · Eligible stays 198 · Observed rate 71.72% · Lower 95% interval 65.17% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.97% |
95.27%
0.7 pts better
|
Numerator 119 · Denominator 124 |
| Falls with major injury | 0.81% |
0.77%
About the same
|
Numerator 1 · Denominator 124 |
| Discharge self-care score | 71.91% |
53.69%
18.2 pts better
|
Numerator 64 · Denominator 89 |
| Discharge mobility score | 51.69% |
50.94%
0.8 pts better
|
Numerator 46 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 4 · Denominator 124 · Adjusted rate 4.25% |
| Healthcare-associated infections requiring hospitalization | 4.91% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 0.86% · Lower 95% interval 2.58% |
| Staff COVID-19 vaccination coverage | 28.57% |
8.2%
20.4 pts better
|
Numerator 28 · Denominator 98 |
| Staff flu vaccination coverage | 69.86% |
42%
27.9 pts better
|
Numerator 146 · Denominator 209 |
| Discharge function score | 66.29% |
56.45%
9.8 pts better
|
Numerator 59 · Denominator 89 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 26.98% |
25.2%
1.8 pts better
|
Numerator 17 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.7
1.5 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
93.5%
5.3 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.4%
2.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
7.4%
6.8 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.0%
1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 4.2% · Q4 7.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
11.2%
2.4 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 19.2% · Q4 11.1% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
20.6%
1 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 20.0% · Q3 23.8% · Q4 25.0% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.0% |
15.2%
2.8 pts worse
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
14.6%
3.6 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.2% · Q3 11.5% · Q4 19.2% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.8%
0.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
22.4%
3.4 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.8% · Q3 43.0% · Q4 32.7% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.4% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.5% |
76.4%
14.9 pts worse
|
81.7%
20.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.1% · Q2 68.0% · Q3 57.1% · Q4 51.4% · 4Q avg 61.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.8%
3.1 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 2.1% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.8% |
75.6%
16.8 pts worse
|
79.7%
20.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
20.3%
0.3 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 16.5% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-15 · Fire 2022-09-15
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-09
F · Potential for more than minimal harm
2022-09-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-23
F · Potential for more than minimal harm
2021-07-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Not marked corrected
F · Potential for more than minimal harm
2021-07-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-18
F · Potential for more than minimal harm
2021-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-19
E · Potential for more than minimal harm
2021-07-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-01-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-15
G · Actual harm
2022-09-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-10-24
F · Potential for more than minimal harm
2021-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-19
E · Potential for more than minimal harm
2021-07-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-07-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-07-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-27
Penalties and ownership
What sits behind the stars
Ownership
Childs, Bryon
Corporate Officer · Individual
Christian Living Neighborhoods
Operational/Managerial Control · Organization
Fralick, Traci
Corporate Director · Individual
Franken, Jan
Operational/Managerial Control · Individual
Keller, Jayne
Corporate Officer · Individual
Vitale-Aussem, Jill
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
South Valley Post Acute Rehabilitation
Denver, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brookshire Post Acute
Denver, CO
2-star overall rating with 1-star inspections with abuse icon flag with $75,713 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Amberwood Post Acute
Denver, CO
2-star overall rating with 2-star inspections with $9,636 in total fines with 17 recent health deficiencies
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