Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

SUITES AT HOLLY CREEK CARE CENTER, THE

CENTENNIAL, CO · 25 certified beds · Last Life Safety survey November 21, 2024

CMS Certification Number 065395 · first certified March 2009

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

CMS's current file

Life Safety surveys

CMS's current file

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CO

37 citations — more than 95% 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

Improvingfewer citations at the latest survey than at its earlier surveys in CMS's current file.

The latest survey found 4 citations; the earlier surveys on file averaged 16.5. 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: May 2026 to December 2026. This facility’s last Life Safety survey was November 2024. Facilities in CO are typically surveyed 18–25 months after the last one (median 21), measured over 187 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 about three years in Virginia. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 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 37 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.

How that compares

Citations in CMS's current file

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

Citations in CMS's current file, compared
Measure	Citations
This facility	37
Median facility in CO	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 25, 2022	22
July 31, 2023	11
November 21, 2024	4

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	3	2024-11-21
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-11-21
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	2	2023-07-31
K-0541	Install properly constructed and protected linen or trash chutes.	2	2023-07-31
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2023-07-31
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-11-21
K-0324	Provide properly protected cooking facilities.	2	2023-07-31
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.	2	2023-07-31

What the citations cover

Citations by CMS category

Smoke Deficiencies 15
Egress Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 6
Services Deficiencies 5
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	15
Egress Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	6
Services Deficiencies	5
Miscellaneous Deficiencies	4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 21, 2024 — 4 citations

Citations issued on November 21, 2024
Tag	What the surveyor checks	Status
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 8, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 23, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 8, 2025)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (January 6, 2025)

July 31, 2023 — 11 citations

Citations issued on July 31, 2023
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 (September 26, 2023)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (September 6, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (September 6, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 6, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 26, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 26, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 26, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 26, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (September 6, 2023)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (September 6, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 6, 2023)

May 25, 2022 — 22 citations

Citations issued on May 25, 2022
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 (August 3, 2022)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (August 3, 2022)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (August 3, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 3, 2022)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (August 3, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 3, 2022)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (August 3, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 3, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (August 3, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 3, 2022)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (August 3, 2022)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (August 3, 2022)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (August 3, 2022)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (August 3, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 3, 2022)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (August 3, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (August 3, 2022)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (August 3, 2022)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (August 3, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (August 3, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 3, 2022)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (August 3, 2022)

Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.