What is Suites at Holly Creek Care Center, the's Medicare star rating?

CMS rates Suites at Holly Creek Care Center, the 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 5 for quality measures (CMS data as of September 1, 2026).

How many deficiencies did Suites at Holly Creek Care Center, the get at its last inspection?

3 health deficiencies at the standard inspection on November 21, 2024. The Colorado average is 8.7.

Does Suites at Holly Creek Care Center, the accept Medicaid?

CMS lists it as "Medicare", so it is not certified for Medicaid.

Who owns Suites at Holly Creek Care Center, the?

CMS lists 19 owners and managers. Legal business name: CHRISTIAN LIVING NEIGHBORHOODS.

Suites at Holly Creek Care Center, the: Inspections

The record in brief

At its most recent standard inspection, on November 21, 2024, inspectors cited 3 health deficiencies (the Colorado average is 8.7, the national average 9.2).

Of 7 health citations since May 2022, 2 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $21,678 in the last three years; the largest was $21,678, and the latest is dated November 21, 2024.

Nurses and nurse aides worked 5.75 hours per resident per day, against 3.72 across Colorado and 3.86 nationally. Registered nurses accounted for 1.60 of those hours.

25.8% of nursing staff left within the year CMS measured (Colorado average 47.1%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

305/22

107/23

311/24

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 7 health citations on file.

Severity

Isolated

Pattern

Widespread

Immediate jeopardy

Actual harm

Potential for more than minimal harm

Potential for minimal harm

November 21, 2024Standard inspection · 3 citations

G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) November 29, 2024

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on [DATE] for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. Preventative measures to protect the resident's heels were not implemented until after the development of the blister on 8/2/24. [...]
E

Provide and implement an infection prevention and control program.

F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 17, 2024

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure staff followed appropriate infection control practices while cleaning resident rooms.
D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 17, 2024

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#4 and #10) of two of 20 sample residents remained free from accidents hazards. Specifically, the facility failed to ensure Resident #4 and Resident #10 had a physician's order, a consent and a completed safety assessment before the implementation of a floor to ceiling transfer pole by the resident's bed.

July 31, 2023Standard inspection · 1 citation

G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) August 31, 2023

Inspectors wroteIII. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic kidney disease, polyneuropathy (malfunction of small vessels throughout the body), hypotension (low blood pressure), and complete atrioventricular block (electrical signals cannot pass to the chambers of the heart to allow proper blood flow). The 6/15/23 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was 13 out of 15 indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and physical help, in part, with bathing/showering. The resident was unsteady on his feet and was not able to stabilize with staff assistance. [...]

May 25, 2022Standard inspection · 3 citations

E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 24, 2022

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely for two (Resident #9 and Resident #13) of 16 out 20 residents and addressed continued call light complaints voiced during resident council for several months.
D

Ensure medication error rates are not 5 percent or greater.

F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2022

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 12%, or three errors out of 25 opportunities for error; registered nurse (RN) #1 failed to ensure Resident #4 had an order to crush medications prior to administration; and RN #1 crushed a medication for blood pressure (Metoprolol Succinate) which should not have been crushed.
D

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.

F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2022

Inspectors wroteBased on resident record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#6) of two out of 20 sample residents. Specifically the facility failed to: -Ensure adequate and timely documentation and coordination of care with the hospice agency; and, -Ensure there was written documentation of hospice visits for approximately four months, which included hospice staff not speaking with the facility nursing staff about their visits. There was no documentation the resident received from hospice the care planned twice weekly showers.

Fire safety inspections

37 fire safety citations on file: 4 on November 21, 2024, 11 on July 31, 2023, 22 on May 25, 2022.

Every fire safety citation37 citations

F
Have approved installation, maintenance and testing program for fire alarm systems.

K 345 · November 21, 2024 · Corrected (the home has a date of correction)
F
Inspect, test, and maintain automatic sprinkler systems.

K 353 · November 21, 2024 · Corrected (the home has a date of correction)
F
Have restrictions on the use of highly flammable decorations.

K 753 · November 21, 2024 · Corrected (the home has a date of correction)
E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

K 321 · November 21, 2024 · Corrected (the home has a date of correction)
F
Install proper backup exit lighting.

K 281 · July 31, 2023 · Corrected (the home has a date of correction)
F
Install emergency lighting that can last at least 1 1/2 hours.

K 291 · July 31, 2023 · Corrected (the home has a date of correction)
F
Have properly located and lighted "Exit" signs.

K 293 · July 31, 2023 · Corrected (the home has a date of correction)
F
Have approved installation, maintenance and testing program for fire alarm systems.

K 345 · July 31, 2023 · Corrected (the home has a date of correction)
F
Inspect, test, and maintain automatic sprinkler systems.

K 353 · July 31, 2023 · Corrected (the home has a date of correction)
F
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · July 31, 2023 · Corrected (the home has a date of correction)
E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

K 223 · July 31, 2023 · Corrected (the home has a date of correction)
E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

K 321 · July 31, 2023 · Corrected (the home has a date of correction)
E
Provide properly protected cooking facilities.

K 324 · July 31, 2023 · Corrected (the home has a date of correction)
E
Install properly constructed and protected linen or trash chutes.

K 541 · July 31, 2023 · Corrected (the home has a date of correction)
D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

K 521 · July 31, 2023 · Corrected (the home has a date of correction)
K
Provide properly protected cooking facilities.

K 324 · May 25, 2022 · Corrected (the home has a date of correction)
E
Install emergency lighting that can last at least 1 1/2 hours.

K 291 · May 25, 2022 · Corrected (the home has a date of correction)
E
Have approved installation, maintenance and testing program for fire alarm systems.

K 345 · May 25, 2022 · Corrected (the home has a date of correction)
E
Install an approved automatic sprinkler system.

K 351 · May 25, 2022 · Corrected (the home has a date of correction)
E
Inspect, test, and maintain automatic sprinkler systems.

K 353 · May 25, 2022 · Corrected (the home has a date of correction)
E
Properly select, install, inspect, or maintain portable fire extinguishes.

K 355 · May 25, 2022 · Corrected (the home has a date of correction)
E
Install corridor and hallway doors that block smoke.

K 363 · May 25, 2022 · Corrected (the home has a date of correction)
E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

K 372 · May 25, 2022 · Corrected (the home has a date of correction)
E
Have properly installed electrical wiring and gas equipment.

K 511 · May 25, 2022 · Corrected (the home has a date of correction)
E
Have simulated fire drills held at unexpected times.

K 712 · May 25, 2022 · Corrected (the home has a date of correction)
E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

K 914 · May 25, 2022 · Corrected (the home has a date of correction)
E
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · May 25, 2022 · Corrected (the home has a date of correction)
D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

K 223 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.

K 232 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

K 343 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have elevators that firefighters can control in the event of a fire.

K 531 · May 25, 2022 · Corrected (the home has a date of correction)
D
Install properly constructed and protected linen or trash chutes.

K 541 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

K 741 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have restrictions on the use of portable space heaters.

K 781 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have power receptacles that are properly grounded.

K 912 · May 25, 2022 · Corrected (the home has a date of correction)
D
Ensure proper usage of power strips and extension cords.

K 920 · May 25, 2022 · Corrected (the home has a date of correction)
D
Have proper medical gas storage and administration areas.

K 923 · May 25, 2022 · Corrected (the home has a date of correction)

Fines and payment denials

Date	Penalty	Amount or length
November 21, 2024	Fine	$21,678

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

Measure	This home	Colorado	United States
All nursing staff (RN, LPN and aides)	5.75	3.72	3.86
Registered nurses	1.60	0.82	0.69
All nursing staff on weekends	5.08	3.29	3.42
Nurse aides	3.22
Licensed practical nurses	0.93
Nursing staff turnover (share who left in a year)	25.8%	47.1%	45.8%
Registered nurse turnover	12.5%	44.6%	42.9%
Administrators who left	1

CMS expects 3.65 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.01 on weekdays and 5.08 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.95 in April to June 2025 to 5.75 in January to March 2026.

Quarter	All nursing staff	Registered nurses	Weekdays	Weekends	Contract staff share	Days with no RN hours	Residents a day
Jan to Mar 2026	5.75	1.60	6.01	5.08	8.7%	0 of 90	25
Oct to Dec 2025	5.95	1.68	6.32	5.02	8.9%	0 of 92	25
Jul to Sep 2025	6.24	2.01	6.58	5.38	8.4%	0 of 92	23
Apr to Jun 2025	5.95	1.71	6.22	5.28	5.0%	0 of 91	24
United States, Jan to Mar 2026	3.75	0.62	3.92	3.33	5.3%	0.5% of days
Colorado, Jan to Mar 2026	3.59	0.76	3.75	3.18	5.9%	0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Colorado

Job	Median	Middle half	Employed
Colorado, all employers
CNAs (nursing assistants)	$22.78	$21.42 to $24.00	22,240
LPNs and LVNs	$35.52	$29.76 to $38.37	4,920
Registered nurses	$48.20	$40.67 to $52.37	54,490
United States, nursing care facilities
CNAs (nursing assistants)	$20.67	$17.91 to $22.55	534,270
LPNs and LVNs	$33.86	$30.05 to $37.40	188,210
Registered nurses	$41.11	$37.85 to $47.68	142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

Measure	This home	Colorado	US
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1	32.4	13.4	13.9
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1	0.0	0.6	0.8
Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1	1.6	1.4	1.6
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1	10.6	3.4	3.2
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1	0.6	1.6	1.6
Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1	1.3	3.4	4.6
Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1	10.3	20.0	15.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231	18.7	20.3	23.8
Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231	12.6	12.1	12.0

Owners and operators

Legal business name: CHRISTIAN LIVING NEIGHBORHOODS.

Name	Role	Type	Since
Christian Living Neighborhoods	Direct ownership interest	Organization	09/01/2011
Fralick, Traci	Corporate director	Individual	11/05/2018
Vitale-Aussem, Jill	Corporate director	Individual	11/01/2020
Childs, Bryon	Corporate officer	Individual	05/28/2007
Keller, Jayne	Corporate officer	Individual	04/01/2021
Christian Living Neighborhoods	Operational/managerial control	Organization	09/01/2011
Chapman, Madelyn	Operational/managerial control	Individual	10/23/2020
Franken, Jan	Operational/managerial control	Individual	07/09/2007
Childs, Bryon	Trustee of the SNF	Individual	05/28/2007
Fralick, Traci	Trustee of the SNF	Individual	11/05/2018
Keller, Jayne	Trustee of the SNF	Individual	04/01/2021
Vitale-Aussem, Jill	Trustee of the SNF	Individual	11/01/2020
Christian Living Neighborhoods	Adp of the SNF	Organization	03/26/2025
Chapman, Madelyn	Adp of the SNF	Individual	10/23/2020
Childs, Bryon	Adp of the SNF	Individual	05/28/2007
Fralick, Traci	Adp of the SNF	Individual	11/05/2018
Franken, Jan	Adp of the SNF	Individual	07/09/2007
Keller, Jayne	Adp of the SNF	Individual	04/01/2021
Vitale-Aussem, Jill	Adp of the SNF	Individual	11/01/2020

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on November 21, 2024: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 1 problem in this area, most recently on November 21, 2024: "Provide and implement an infection prevention and control program."
How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on May 25, 2022: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 1 problem in this area, most recently on May 25, 2022: "Ensure medication error rates are not 5 percent or greater."
How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

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Orchard Park Health Care Center
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Brookdale Greenwood Village
Greenwood Village, 2.1 mi · 3 of 5 stars · 32 citations
Cherrelyn Healthcare Center
Littleton, 3.9 mi · 4 of 5 stars · 37 citations
VI at Highlands Ranch Skilled Nursing
Highlands Ranch, 3.9 mi · 5 of 5 stars · 3 citations
Julia Temple Healthcare Center
Englewood, 4.7 mi · 3 of 5 stars · 13 citations
Wellsprings Care Center
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Englewood Post Acute and Rehabilitation
Englewood, 4.9 mi · 4 of 5 stars · 16 citations

Colorado contacts for a concern about a nursing home

These are the official offices in Colorado. NursingHomeClear cannot take or act on complaints.

Inspections and complaints: Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Services Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
Resident advocate: Colorado State Long-Term Care Ombudsman Program, 303-862-3524. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
State inspection reports: Find and compare facilities, where Colorado publishes its own records on licensed homes.

Common questions

What is Suites at Holly Creek Care Center, the's Medicare star rating?: CMS rates Suites at Holly Creek Care Center, the 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Suites at Holly Creek Care Center, the get at its last inspection?: 3 health deficiencies at the standard inspection on November 21, 2024. The Colorado average is 8.7.
Has Suites at Holly Creek Care Center, the been fined?: Yes. CMS lists 1 fine totaling $21,678 in the last three years.
Does Suites at Holly Creek Care Center, the accept Medicaid?: CMS lists it as "Medicare", so it is not certified for Medicaid.
Who owns Suites at Holly Creek Care Center, the?: CMS lists 19 owners and managers. Legal business name: CHRISTIAN LIVING NEIGHBORHOODS.

Sources

Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
Owners: CMS Ownership. Penalties: CMS Penalties.
Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.