Cycle 1
Health 2024-04-25 · Fire 2024-04-25
8 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Centennial, CO
Suites At Someren Glen Care Center, The
3-star overall rating with 3-star inspections with $36,446 in total fines with 8 recent health deficiencies
5000 E Arapahoe Rd, Centennial, CO
(303) 779-5000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
84
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
1.24
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
4.71
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,762
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.72% · Performance 22.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.43% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 78.79% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.25
Baseline 4.15 hours · Performance 4.29 hours · Measure score 4.25 · Achievement 4.25 · Improvement 0.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.3% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 214 · Observed rate 7.01% · Lower 95% interval 6.76% |
| Discharge to community | 68.76% |
50.57%
18.2 pts better
|
Better than the National Rate · Eligible stays 195 · Observed rate 62.56% · Lower 95% interval 62.05% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 125 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 55 · Denominator 99 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 44 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 0.74% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 135 · Adjusted rate 0.93% |
| Healthcare-associated infections requiring hospitalization | 8.77% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 10.17% · Lower 95% interval 5.85% |
| Staff COVID-19 vaccination coverage | 5.26% |
8.2%
2.9 pts worse
|
Numerator 8 · Denominator 152 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 51 · Denominator 99 |
| Transfer of health information to provider | 97.22% |
95.95%
1.3 pts better
|
Numerator 35 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 31.94% |
25.2%
6.7 pts better
|
Numerator 23 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 2.1 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 60.8% |
93.5%
32.7 pts worse
|
93.4%
32.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 48.4% · Q3 86.7% · Q4 78.8% · 4Q avg 60.8% |
| 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 | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.2% · Q3 3.3% · Q4 1.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
7.4%
5.6 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 1.9% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.0%
1.1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.1% · Q3 4.9% · Q4 2.1% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
11.2%
2.2 pts worse
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 16.0% · Q3 14.3% · Q4 12.5% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
20.6%
4.3 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 16.7% · Q3 16.1% · Q4 17.5% · 4Q avg 16.3% · 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 · 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 | 30.4% |
15.2%
15.2 pts worse
|
16.3%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 33.6% · 4Q avg 30.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.2% |
14.6%
13.6 pts worse
|
14.9%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 27.3% · Q3 31.6% · Q4 28.9% · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.8%
About the same
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.5%
2.3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 5.1% · Q4 6.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.8% |
22.4%
17.4 pts worse
|
19.8%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.5% · Q2 32.5% · Q3 42.1% · Q4 34.2% · 4Q avg 39.8% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
3.7%
0.8 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 5.4% · Q3 1.1% · Q4 1.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.1% |
76.4%
45.3 pts worse
|
81.7%
50.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 21.7% · Q3 29.3% · Q4 49.7% · 4Q avg 31.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
12.8%
1.6 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.7% · Q3 2.0% · Q4 2.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.9% |
75.6%
43.7 pts worse
|
79.7%
47.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
20.3%
3.6 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 23.9% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-12 · Fire 2020-02-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2020-02-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-03-12
F · Potential for more than minimal harm
2020-02-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-03-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-30
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 2025-06-12
D · Potential for more than minimal harm
2025-04-30
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 2025-06-12
G · Actual harm
2024-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-04-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
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 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-05-23
G · Actual harm
2020-02-12
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 2020-03-20
F · Potential for more than minimal harm
2020-02-12
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 2020-03-20
F · Potential for more than minimal harm
2020-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-03-20
F · Potential for more than minimal harm
2019-02-07
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 2019-03-20
E · Potential for more than minimal harm
2019-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-19
D · Potential for more than minimal harm
2019-02-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-03-12
Penalties and ownership
What sits behind the stars
$36,446
2024-04-25
Fine
Fine · fine $36,446
Fine
$0
2024-04-25
Payment Denial
Payment Denial · denial start 2024-05-23 · 32 days
32 day denial
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
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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