01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-11-21 | 3 | 2024-11-21 | 4 |
| Cycle 2 | 2023-07-31 | 1 | 2023-07-31 | 11 |
| Cycle 3 | 2022-05-25 | 3 | 2022-05-25 | 23 |
CMS CCN 0653952026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Suites At Holly Creek Care Center, The
5590 E Peakview Ave · Centennial, CO 80121 · Arapahoe County
Certified beds25CMS provider file
Recent citation rows45current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
45 rows in the current release
3 rows carry G–L scope/severity codes; 1 carry J–L. 9 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-11-21 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-11-292024-11-21 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-12-172024-11-21 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-12-172024-11-21 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-01-082024-11-21 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-12-232024-11-21 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-01-082024-11-21 · FIREK0753Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2025-01-062023-08-30 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2023-09-06 · complaint2023-07-31 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-08-312023-07-31 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2023-09-262023-07-31 · FIREK0281Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2023-09-062023-07-31 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-09-062023-07-31 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2023-09-062023-07-31 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-09-262023-07-31 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-09-262023-07-31 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-09-262023-07-31 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-09-262023-07-31 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-09-062023-07-31 · FIREK0541Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Correction field: Deficient, Provider has date of correction · 2023-09-062023-07-31 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-09-062022-05-25 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2022-06-242022-05-25 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2022-06-242022-05-25 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-06-242022-05-25 · FIREK0223Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2022-08-0303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-11-21 | Fine | $21,678 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHRISTIAN LIVING NEIGHBORHOODSOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2011
- FRALICK, TRACIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/05/2018
- VITALE-AUSSEM, JILLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2020
- CHILDS, BRYONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/28/2007
- KELLER, JAYNEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2021
- CHRISTIAN LIVING NEIGHBORHOODSOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2011
- CHAPMAN, MADELYNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/23/2020
- FRANKEN, JANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/09/2007
- CHILDS, BRYONIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 05/28/2007
- FRALICK, TRACIIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 11/05/2018
- KELLER, JAYNEIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 04/01/2021
- VITALE-AUSSEM, JILLIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 11/01/2020
- CHRISTIAN LIVING NEIGHBORHOODSOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- CHAPMAN, MADELYNIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/23/2020
- CHILDS, BRYONIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/28/2007
- FRALICK, TRACIIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/05/2018
- FRANKEN, JANIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/09/2007
- KELLER, JAYNEIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.75per resident day
RN hours1.60per resident day
Weekend nurse hours5.08per resident day
Staff turnover25.8%CMS reported field
06 / LOCAL RECORDS
Open the Centennial ledger →