Cycle 1
Health 2024-11-21 · Fire 2024-11-21
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Centennial, CO
Suites At Holly Creek Care Center, The
5-star overall rating with 4-star inspections with $42,056 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5590 E Peakview Ave, Centennial, CO
(720) 266-5888
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-03-27
CMS approved date
Coverage
Medicare
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
2.01
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.41
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
6.24
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.84
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
5.38
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.44
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.14
CMS adjusted RN staffing hours
Adjusted total hours
6.65
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
17%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,066
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.11% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.75% · Performance 8.06% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.58
Performance 53.12% · Measure score 2.58 · Achievement 2.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 9.35% · Lower 95% interval 7.5% |
| Discharge to community | 64.82% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 102 · Observed rate 64.71% · Lower 95% interval 56.51% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 77.27% |
95.27%
18 pts worse
|
Numerator 34 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 18 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 25% |
8.2%
16.8 pts better
|
Numerator 16 · Denominator 64 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 68 · Denominator 68 |
| Discharge function score | 60.61% |
56.45%
4.2 pts better
|
Numerator 20 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| 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 | 4.5% |
3.4%
1.1 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.0%
0.4 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
11.2%
0.4 pts worse
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
20.6%
6.3 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.5% |
14.6%
17.9 pts worse
|
14.9%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.5%
0.2 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.4%
2.8 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
3.7%
1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.6% |
76.4%
1.8 pts worse
|
81.7%
7.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 97.6% · Q3 76.3% · Q4 51.5% · 4Q avg 74.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
12.8%
9.4 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 3.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 2.3% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.6%
24.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
20.3%
10.3 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 30.3% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-31 · Fire 2023-07-31
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2022-05-25 · Fire 2022-05-25
3 health deficiencies
Top issue: Administration (1 deficiency)
23 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-08
F · Potential for more than minimal harm
2023-08-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-07-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-07-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-07-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-31
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-07-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-07-31
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-07-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-06
K · Immediate jeopardy
2022-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
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.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-03
D · Potential for more than minimal harm
2022-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-03
Inspection history
Recent health citations
G · Actual harm
2024-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-21
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 2024-12-17
G · Actual harm
2023-07-31
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 2023-08-31
E · Potential for more than minimal harm
2022-05-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-25
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 2022-06-24
Penalties and ownership
What sits behind the stars
$21,678
2024-11-21
Fine
Fine · fine $21,678
Fine
$20,378
2023-07-31
Fine
Fine · fine $20,378
Fine
$0
2023-07-31
Payment Denial
Payment Denial · denial start 2023-08-29 · 8 days
8 day denial
Ownership
Chapman, Madelyn
Operational/Managerial Control · Individual
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 Director · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 3-star inspections with $36,446 in total fines with 8 recent health deficiencies
#2
Orchard Park Health Care Center
Littleton, CO
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Brookdale Greenwood Village
Greenwood Village, CO
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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