Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Suites At Someren Glen Care Center, The during CMS and state inspections, most recent first.
A facility failed to ensure informed consent was obtained and documented for proposed treatment changes. One resident received psychotropic medications without a consent form showing the risks and benefits were explained, another resident’s Seroquel dose was increased without updated consent from the resident or representative, and a third resident received ceftriaxone for a suspected UTI even though the representative had requested comfort-focused care and no antibiotic treatment.
Failure to Timely Report Abuse Allegations: The facility did not report three abuse allegations to the State Agency within the required two-hour timeframe. The incidents involved alleged verbal abuse between two residents and alleged sexual abuse involving a resident and a CNA. Record review and interviews showed the reports were delayed by about 20 hours, 20 hours, and 90 hours, despite facility policy and staff statements that abuse allegations should be reported immediately.
The facility failed to thoroughly investigate multiple abuse and neglect allegations involving a CNA and two residents. One resident with COPD, depression, muscle weakness, and moderate cognitive impairment reported inappropriate touching of her breasts, but the investigation lacked an interview with the CNA, resident representative follow-up, and staff interviews. Another resident with Parkinson’s disease, GERD, anxiety, and depression reported sexualized touching during a transfer, but the file lacked the CNA interview, related education, and observation of transfer technique. A separate neglect allegation involved a CNA sleeping on shift while residents were on the unit, but the investigation did not include the reporter’s statement or complete documentation of work restriction during the investigation.
A resident with orthostatic hypotension, dementia, chronic kidney disease, and other comorbidities had a physician order for midodrine with a hold parameter to stop the dose when systolic BP exceeded 100 mmHg. Review of the MAR showed that nursing staff administered midodrine 49 times despite documented systolic BP readings above the ordered threshold. Facility policy required medications to be given exactly as prescribed and vital signs to be obtained and reviewed before administration, but interviews with the regional nurse, medical director, NHA, and nursing staff confirmed a systemic pattern of not following BP parameters for this medication, resulting in a significant medication error.
A resident with severe dementia and Parkinson's disease was physically redirected by a CNA after spilling a drink, without any verbal explanation or reassurance, contrary to the individualized care plan that required verbal and person-centered interventions. Staff interviews confirmed that the care plan was not followed, resulting in a failure to provide a dignified and appropriate response.
Two residents with cognitive and physical impairments did not receive timely assistance with toileting and incontinence care, resulting in prolonged periods without being checked or changed. Staff did not follow care plans or facility policy, and one resident was found soiled with urine and skin redness, while another remained wet for over five hours due to delayed care and inability to use the call light.
The facility failed to provide timely interventions and proper documentation for two residents at risk of pressure injuries, leading to the development and worsening of stage 3 and unstageable pressure injuries. Staff did not offer frequent repositioning or toileting, and there was a lack of documentation for refusals of care.
The facility failed to complete annual performance reviews and provide regular in-service education for five CNAs. The NHA and DON confirmed that the evaluations were not conducted as required, and a previously scheduled evaluation fair was poorly attended due to an illness outbreak.
The facility failed to post accurate staffing information, including the actual working hours of licensed and unlicensed staff, on multiple days. Observations and staff interviews confirmed that the posted information was either outdated or incomplete.
The facility failed to properly store and label medications, including expired medications in a medication cart, unlabeled insulin pens, and medications stored in a dormitory-style refrigerator with significant ice build-up. The LPN and DON were unaware of proper storage requirements.
The facility failed to maintain an infection control program, as a resident's foley catheter bag was repeatedly found on the floor, and mechanical lifts were not disinfected between uses. Staff interviews confirmed these practices, which could lead to infections.
The facility failed to ensure that a CNA received the required 12 hours of annual in-service training, with one CNA completing only 0.75 hours. Staff interviews confirmed awareness of the deficiency, and a new staff development coordinator was hired to address training compliance.
Failure to Obtain and Document Informed Consent for Psychotropic Medications and Antibiotic Therapy
Penalty
Summary
The facility failed to ensure residents were fully informed of the treatment, including the risks and benefits, of proposed care and that they could choose an alternative option if they preferred. The deficiency involved three residents: one resident who was cognitively intact and receiving psychotropic medications, one resident with severe cognitive impairment whose psychotropic dose was increased, and one resident with severe cognitive impairment whose representative did not want antibiotic treatment for a suspected urinary tract infection. For the cognitively intact resident, the record showed orders for risperidone for dementia with behaviors and sertraline for depression, and the first doses were administered. The consent form for these psychotropic medications did not reveal whether the facility explained the risks versus benefits of the medications to the resident or representative. Staff interviews indicated nursing staff were responsible for obtaining consent for medications with black box warnings and were expected to explain side effects, monitoring, and risks versus benefits, but the resident’s consent form did not document that information. For the resident whose psychotropic medication was increased, the record showed an initial consent for Seroquel 12.5 mg twice daily, followed by recommendations and administration changes that increased the dose to 25 mg twice daily and later to 50 mg twice daily. The chart did not contain documentation that the resident’s representative was informed of and agreed to the dose increase, and there were no updated psychotropic informed consent forms for the higher dose. Staff interviews confirmed that a new consent should have been obtained when the dose increased, but none could be found. For the resident whose representative opposed antibiotic treatment, the resident had severe cognitive impairment, a MOST form for comfort-focused treatment only, and a durable power of attorney naming the wife as representative. After the resident developed signs of a possible UTI, ceftriaxone was ordered and two doses were administered. Documentation showed the representative requested that treatment be held until hospice re-evaluated the resident and later stated she did not want antibiotic therapy, but the facility still administered antibiotics before the order was cancelled. The record also showed the breakdown in communication between the on-call physician and nursing staff could not be verified.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey and Certification Agency within the required two-hour timeframe for three of six abuse allegations. The incidents included an alleged verbal abuse between two residents on 2/18/26, an alleged sexual abuse between a resident and CNA #6 on 12/19/25, and another alleged sexual abuse between a resident and CNA #6 on 1/3/26. The facility’s abuse policy stated that suspected or actual abuse must be reported and that the executive director would ensure applicable regulatory agencies were notified within 24 hours of becoming aware of the allegation; staff interviews also reflected that abuse should be reported immediately and that the State Agency should be notified within two hours. Record review showed the alleged sexual abuse involving Resident #82 and CNA #6 occurred at 3:45 p.m. on 12/19/25, but the report to the State Agency was not made until 11:51 a.m. on 12/20/25, about 20 hours later. The alleged sexual abuse involving Resident #79 and CNA #6 occurred at 7:00 p.m. on 1/3/26, but was not reported until 1/7/26 at 1:49 p.m., about 90 hours later. The alleged verbal abuse between Resident #46 and Resident #56 occurred at 4:00 p.m. on 2/18/26, but was not reported until 12:15 p.m. on 2/19/26, about 20 hours later. Interviews with the NHA, social services assistant #2, and the DON confirmed the facility’s expectation that abuse allegations be reported promptly, including within two hours.
Failure to Thoroughly Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate three allegations involving abuse and neglect. The report states that the facility did not fully investigate a sexual abuse allegation involving CNA #6 and Resident #82, a sexual abuse allegation involving CNA #6 and Resident #79, and a neglect allegation involving CNA #5. The facility policy required a detailed investigation, immediate initiation by the senior staff member on duty, documentation of all relevant evidence, and determination of whether the allegation was verified, not verified, or inconclusive. For Resident #82, who had COPD, depression, muscle weakness, difficulty walking, overactive bladder, and moderate cognitive impairment with a BIMS score of 10, the investigation documented that she reported CNA #6 had his hands where they should not be and clarified that she meant her breasts. The interview with Resident #82 occurred three days after the allegation. The investigation did not document an interview with CNA #6, did not document that the resident’s representative was informed or interviewed, did not include staff interviews about the incident, and the resident-specific interview questions used for other residents did not address the sexual abuse allegation. The resident later told surveyors that an employee had touched her inappropriately and that she had reported it with her pastor. For Resident #79, who had Parkinson’s disease, GERD, anxiety, depression, and a BIMS score of 12, the investigation documented that she said CNA #6 patted the area below her bottom during a transfer and that she felt the contact was sexual in nature. The facility suspended CNA #6, but the investigation did not include documentation of his interview, education provided to him, any training related to abuse and transfers, or attempts to observe and assess his transfer technique. For the neglect allegation involving CNA #5, the facility documented that he was observed sleeping on the overnight shift while residents were on the unit. The investigation included interviews and a review of personnel and call light records, but it did not include CNA #4’s statement or interview, and the facility could not provide documentation showing CNA #5 was not allowed to work during the investigation. Staff interviews also indicated CNA #5 had a pattern of sleeping on shift, and the executive director and DON stated they were unaware of some of the reporter’s statements when reviewing the case.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was kept free from significant medication errors when nursing staff did not administer a prescribed blood pressure medication according to physician-ordered parameters. Record review showed that the resident, an individual over 70 years old with orthostatic hypotension, unspecified dementia with behavioral disturbances, chronic kidney disease, hypomagnesemia, and osteoarthritis, had an order for midodrine 10 mg by mouth twice daily, later increased to three times daily, with instructions to hold the dose if the systolic blood pressure (SBP) was greater than 100 mmHg. Despite this clear order, the medication administration record documented that midodrine was administered 49 times when the resident’s SBP was outside the ordered parameters. The resident’s medical record indicated that the midodrine order with SBP parameters was in place from August through at least early September, and the medication administration record from 8/12/25 to 9/10/25 showed repeated administrations that did not comply with the hold parameter. These administrations occurred even when the documented SBP exceeded the threshold at which the medication was to be withheld. The facility’s own Medication Administration Guidelines policy required that medications be administered as prescribed, that nurses review and confirm orders on the MAR, obtain and record vital signs as necessary prior to administration, and clarify any questionable orders with the prescriber or pharmacy before giving the medication. Nonetheless, the documented practice for this resident did not align with those requirements. Interviews with facility staff further confirmed that the problem was systemic and involved multiple nurses not following physician orders for medication parameters. The regional corporate nurse stated that an audit of the resident’s electronic medical record revealed that nursing staff had failed to hold midodrine 49 times when the SBP was over 100 mmHg. The medical director reported that there was a systemic problem in the facility with following physician orders for medication parameters and stated that he expected nursing staff to follow those orders. The NHA also acknowledged a systemic problem with nurses following physician orders related to medication administration and adherence to blood pressure parameters. Nursing staff interviews referenced subsequent training on medication parameters, indicating that prior to that training, nurses had not consistently followed the ordered blood pressure parameters for midodrine, which led to the cited deficiency.
Failure to Provide Dignified, Person-Centered Redirection for Resident with Dementia
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to honor a resident's right to a dignified existence and person-centered care. The resident, a 70-year-old individual with severe dementia, mood disturbances, and Parkinson's disease, was observed during a lunch meal service to have spilled a glass of clear liquid on the food preparation counter. The CNA approached the resident from behind and physically redirected her by placing both hands under her armpits and moving her away from the area, without providing any verbal explanation, reassurance, or calming interaction. This action was not in accordance with the resident's care plan, which specified the use of verbal redirection, allowing time for response, and other person-centered interventions tailored to her cognitive and communication impairments. The resident's care plans, which addressed her impaired communication and cognitive functioning, outlined interventions such as providing verbal and visual cues, explaining procedures, and using calm, simple language. Physical redirection was not included as an intervention. Staff interviews confirmed that the CNA did not follow the care plan and that the expected approach was to use verbal redirection or comforting objects. The incident demonstrated a failure to implement the individualized care plan interventions, resulting in the resident not experiencing a dignified and person-centered response during the incident.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment and total dependence on staff for ADLs, observations revealed that she was not offered or provided with incontinence care or toileting assistance for a period of four hours. Staff interviews confirmed that the resident was last changed at 7:45 a.m., and no further care was provided until a hospice aide arrived for a scheduled shower, at which point the resident was found soiled with urine and had a reddened area near her tailbone. The care plan for this resident required assistance with toileting throughout the day and always upon rising, but this was not followed during the observed period. Another resident, who had moderate cognitive impairment and required staff assistance for all ADLs, was also not provided with timely incontinence care. Observations showed that the resident was not checked or changed from 5:03 a.m. until 10:40 a.m., a period of over five hours. During this time, staff did not offer toileting or incontinence care before or after breakfast, and the resident was found to be wet and soiled when finally changed. Interviews with staff indicated that care was delayed due to workload and assumptions that the resident would use the call light if assistance was needed. However, the resident was unable to effectively use the call light due to physical limitations, and there was no documentation of her refusing care. Both residents had care plans and facility policies in place that required regular assessment and assistance with toileting and incontinence care, but these were not consistently implemented. Staff interviews revealed inconsistent practices and reliance on subjective judgment rather than adherence to scheduled care routines. The lack of timely incontinence care resulted in residents remaining soiled for extended periods, contrary to their care plans and facility policy.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two residents. Resident #27, who was at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium. The care plan for Resident #27 did not include interventions to encourage repositioning while sitting in his recliner or frequent toileting/incontinence care. Continuous observations revealed that Resident #27 was not offered frequent repositioning or toileting by the staff, leading to the development of the pressure injuries. Resident #1, who was frequently incontinent of urine and bowel and at risk for developing pressure injuries due to decreased mobility, was identified to have an open area on her coccyx during a routine skin assessment. However, there was no documentation indicating that the wound care physician was notified, and no new physician's orders were obtained to treat the wound. It took 13 days for the facility to initiate treatment for the unstageable pressure wounds on Resident #1's coccyx and left buttock. The care plan for Resident #1 also failed to include interventions for frequent repositioning and incontinent care. Staff interviews revealed that CNAs and LPNs were aware of the need for frequent repositioning and toileting for residents at risk of pressure injuries but failed to document refusals of care or provide the necessary interventions. The Director of Nursing acknowledged that residents should be repositioned every two hours and that refusals should be documented, but there was no evidence of such documentation in the residents' electronic medical records. The facility's failure to provide timely interventions and proper documentation led to the development and worsening of pressure injuries in both residents.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of those reviews for five certified nurse aides. Specifically, the facility had not completed annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8, which would have determined their potential training needs. The facility did not have a performance evaluation policy, as confirmed by the nursing home administrator (NHA). During record review and interviews, it was revealed that the annual performance reviews for the mentioned CNAs were requested but not available. The NHA admitted that the evaluations had not been completed and acknowledged that they should have been done annually. The director of nursing (DON) also confirmed that performance evaluations should be conducted annually and mentioned that a previously scheduled performance evaluation fair was poorly attended due to an illness outbreak. The facility plans to schedule another performance evaluation fair in the near future to comply with the regulations.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a prominent place and readily accessible to residents and visitors. Specifically, the facility did not include the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Observations on multiple days revealed that the staffing information was either not current or did not include the actual working hours for the staff. For instance, on 4/22/24, the staffing information was posted but did not include the actual working hours. Similar issues were observed on 4/23/24, 4/24/24, and 4/25/24, where the posted staffing information was either outdated or incomplete. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the deficiencies. The DON mentioned that a receptionist who only worked occasionally was responsible for the incorrect posting on 4/23/24 and was unsure why the actual working hours were not included. The NHA acknowledged awareness of the regulatory requirement to include actual working hours in the daily staffing post but could not explain why it was not done. Both the DON and NHA indicated that they would take immediate steps to correct the issue.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly in one of three medication carts and one of two medication storage rooms. Specifically, expired medications were found stored with current medications in the medication carts, and insulin pens were not labeled with resident names and open dates. Additionally, medications were stored in a dormitory-style refrigerator/freezer combination, which is not recommended for medication storage due to the risk of freezing medications. An open bottle of Melatonin that expired in January 2024 and a Lantus insulin pen without a resident name or open date were found in the Juniper medication cart. The LPN acknowledged that the expired Melatonin should have been removed and that the insulin pen should have been labeled to ensure proper usage and effectiveness. The Juniper medication room contained a dormitory-style refrigerator with significant ice build-up, which was in contact with a box of Trulicity, potentially compromising the medication's integrity. The LPN and DON were unaware that medications should not be stored in such refrigerators, although temperature logs did not indicate any out-of-range temperatures.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, specifically in the handling of a foley catheter and the cleaning of mechanical lifts. Observations revealed that Resident #69's foley catheter collection bag was repeatedly found on the floor, contrary to the facility's policy that required the catheter to be stored in a dignity bag or placed in a basin to avoid contact with the floor. Interviews with the resident and staff confirmed that the catheter bag was consistently placed on the floor, which could lead to infections due to the unsanitary conditions of the floor. Both the registered nurse and the director of nursing acknowledged that the catheter bag should not be on the floor as it could result in a urinary tract infection for the resident. Additionally, the facility failed to ensure that mechanical lifts were cleaned between residents. A certified nurse aide was observed transferring two residents using the same sit-to-stand mechanical lift without disinfecting it between uses. The aide stated that it was the night shift's responsibility to clean the lifts, while a licensed practical nurse and the director of nursing indicated that the lifts should be cleaned between each use with sanitization wipes. The lack of proper disinfection between uses, especially after the lift was in the bathroom, posed a risk of spreading bacteria among residents.
Failure to Ensure Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, one CNA out of five reviewed had only completed 0.75 hours of the required 12 hours of continued education units (CEU). This deficiency was identified through a review of the CNA's training records and confirmed through staff interviews. The facility's policy, revised in July 2018, mandates comprehensive orientation and training programs to prepare associates for their roles, including legal and regulatory compliance. However, the facility did not adhere to this policy in the case of CNA #9. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility was aware of the deficiency. The DON acknowledged that all CNAs should complete 12 hours of CEU annually and mentioned that CNA #9 had been written up for not meeting this requirement. The NHA indicated that a new staff development coordinator had been hired to track and ensure compliance with training requirements. Despite these measures, the deficiency remained unaddressed at the time of the survey, highlighting a lapse in the facility's training program implementation and oversight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Centennial
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Suites At Holly Creek Care Center, The | 0.6 mi | ★★★★★ | 0 | 0 |
| Orchard Park Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Brookdale Greenwood Village | 2.7 mi | ★★★★★ | 25 | 0 |
| Vi At Highlands Ranch Skilled Nursing | 3.5 mi | ★★★★★ | 0 | 0 |
| Cherrelyn Healthcare Center | 3.5 mi | ★★★★★ | 1 | 0 |
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